Fns-52 Food Requisition

Print

UNITED STATES DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE

STATE

NAME OF DISTRIBUTING AGENCY

OMB FORM APPROVED NO. 0584-0293
Expiration Date: XX/XX/XXXX
TYPE OF ACTION

CHECK ONE ("X")

ADD

FOOD REQUISITION

UNITS

CHANGE

POUNDS

CANCEL

SEE INSTRUCTIONS ON REVERSE
1. COMMODITY (SHORT TITLE) (20)

8.

9.

DELIVERY
ORDER NO.
(4)

10.

ALLOCATION
(5)

ENDING SHIPPING/
DELIVERY DATE
(6)

2. D/A CODE (3)

3. DELIVERY YEAR 4. FISCAL YEAR
5. SECTION OF PUBLIC LAW (3)
(ALPHA) (1)
OF PURCHASE (2)

11. PLANNED PROGRAM USAGE BY OUTLET, ADJ CODE & QUANTITY
FIRST LINE: SHOWS OUTLET(S) (4) AND ADJUSTMENT CODE(S) (1)
SECOND LINE: SHOWS QUANTITY FOR EACH OUTLET (7)
OUTLET 1

OUTLET 2

OUTLET 3

OUTLET 4

12.

FOR FNS USE ONLY
6. REQUISITION NO. (3) 7. STAMP DATE (6)

13.
TOTAL
QUANTITY
(8)

14. DESTINATION
REDO
CODE
(1)

ENTITY CODE
(5)

C/D
(1)

CITY
(16)

The undersigned, being duly authorized to request foods for and on behalf of the agency named above, does hereby certify that local preferences and inventories have been
considered prior to submitting this food request, agrees to accept the food shown hereon upon delivery at destination(s) indicated, and to distribute the entire quantity in
accordance with instructions of the Food and Nutrition Service. The signing of the "Distributing Agency Consignee Receipt" on Form KC-269A by the undersigned or his
designee shall constitute acceptance of the food for and on behalf of the Agency.
16. FOOD AND NUTRITION SERVICE APPROVAL

15. DISTRIBUTING AGENCY CERTIFICATION
A. DATE

B. SIGNATURE

FORM FNS-52 (9/98) Previous editions obsolete

C. TITLE

A. DATE

SBU

B. SIGNATURE

C. TITLE

Electronic Form Version Designed in Adobe 7.1 Version

INSTRUCTIONS
ITEMS
STATE - Enter the name of the State in which the Distributing Agency
is located.
DISTRIBUTING AGENCY - Enter the name of the Distributing
Agency
UNITS OR POUNDS - Place an "X" in the applicable box.
TYPE OF ACTION - Place an "X" in the applicable box.
The numbered blocks will be keyed by FNS Regional Office, as
outlined below. The numbers appearing in parentheses after the block
title show the maximum number of characters that may be keyed.
BLOCK

9. ALLOCATION NUMBER - Enter the allocation number provided
by the FNS Regional Office.
10. ENDING SHIPPING/DELIVERY DATE - The final day of the
shipping/delivery period is required. States may show entire
requested shipping/delivery period if desired.
11. PLANNED PROGRAM USAGE BY OUTLET, ADJUSTMENT
CODE AND QUANTITIY - Enter approved codes for planned
program usage as provided by FNS Regional Office. Enter the
number of Units or Pounds requested for each outlet. The total
of the outlet quantities must equal the quantity shown in the
TOTAL QUANTITY column (Block 12). Each planned usage
outlet may have one approved adjustment code, if needed.

1. COMMODITY - Enter the short title as provided by the FNS
Regional Office. (This must be identical to the short title
given in the FNS commodity file.)

12. TOTAL QUANTITY - Total quantitiy must equal the sum of the
quantities shown in the Quantity columns in Block 11.

2. D/A/ CODE - Enter the three digit code number of the
Distributing Agency.

13. REDONATION CODE - If commodity is to be redonated at
USDA expense, as approved by the FNS Regional Office, enter
"R", if redonation is for information only, enter "S".

3. DELIVERY YEAR - Enter the alphabetical designation,
provided by FNS Regional Office, for delivery year in which
shipment is to be made, regardless of outlet. For example,
all orders requested for shipment between 7/1/82 and
6/30/83 should have a delivery year code D, for all outlets.
4. FISCAL YEAR OF PURCHASE - Enter the fiscal year during
which the commodity will be purchased. This information is
provided in allocations for Group A foods and for Group B
foods through a separate coding sheet available from FNS.
5. SECTION OF PUBLIC LAW - Enter the section of the public
law as advised by the FNS Regional Office.
6. REQUISITION NUMBER - Leave blank. This space for FNS
use only.
7. STAMP DATE - Leave blank. This space for FNS use only.
8. DELIVERY YEAR - Order number assigned by the Distributing
Agency should be expressed in three digits, beginning with
001 for each food unless instructed differently by FNS Regional
Office. If a destination change is necessary to the original
order, the original order must be cancelled and the changed
order would carry the original order number plus an alphabetical
suffix, A, B, or C. suffixes D, E, etc. are used for other types of
delivery order changes, such as when it is necessary to split one
delivery order into two or more. If it is necessary to cancel an
order for any reason other than a destination change after it has
been processed by the Kansas City FSA Commodity Office
(KCCO), the order number shall not be reused; if replacement is
necessary, use a new order number.

14. DESTINATION - (Entity Code, Check Digit Code and City).
Entity and check digit codes provided by KCFO for each given
destination must be used. If the city name is less than 7 digits,
the State 2-letter code must also be shown. If it is necessary to
change the destination for an order already submitted to KCFO,
please follow the instructions for Block 8, Delivery Order
Number.

REMARKS - For use by the Distributing Agency or the FNS Regional
Office. remarks will be key entered at the FNS Regional Office using
established codes for standard remarks, combined code and message,
or free from message. Remarks should be written or typed on the form
on the appropriate order number line. Established remarks codes are
available through FNS Regional Office.
DISTRIBUTION
1. The Distributing Agency shall retain the pink copy and forward the
original and other copies (with carbon inserts) to the FNS Regional
Office. If any remarks are given, the last remarks page may also
be kept by the Distributing Agency as a record.
2 After approval by the FNS Regional Office, a buff copy shall be
returned to the Distributing Agency.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0293. The time
required to complete this collection is estimated to average 2 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information.