NORTHEAST IOWA FOOD BANK

1605 Lafayette St.

Waterloo, IA 50704

Phone: 319-235-0507 or 1-888- NEIFB4U (634-3248)

Fax: 319-235-1027

Date: ______

Name of Agency: ______

Name of Program: ______

Site Address: ______

Phone Number: ______

Email address (required): ______

Director of Agency: ______

Director of Food Program:______

If additional space is required, please attach extra sheets.

Are you a designated 501 © 3 non-profit charitable organization as defined by the Internal Revenue Code Section 170 (e) 3? ______Yes ______No

Tax ID Number ______

Has your organization been in operation for at least 6 months? _____Yes _____No (A copy of the IRS Letter of Determination must accompany this application, if not already on file.)

What is the primary purpose of your agency?

____Emergency Food Provider (Pantry/Shelter)

____Community Meal Program

____On-site Meal Program

____After School Programming

____Other (Describe: ______)

On-site meal/Community Meal programs only:

Does your agency provide meals on your premises? (On-site meal programs only) ____Yes ____No

(If yes, please describe)

How often are meals provided? ____Daily ____Weekly ____Monthly ____Seasonal

Number of people served? _____ Breakfast _____Lunch _____Dinner _____ Holiday

Describe the type of records your agency retains concerning your food program. (i.e.) number of people served, names of people, how often served, number of meals, eligibility; etc. (Please attach blank copies.)

Pantry/Shelter programs only:

Describe the type of records your agency retains concerning your pantry distribution. (i.e.) number of individuals served per month, number of families per month, pounds of grocery products distributed, pounds of grocery products donated from community. Forms used to determine the amount of grocery products distributed to recipients. (Please attach blank copies)

Does your agency distribute Emergency Food Boxes? ____Yes ____No

If yes, please describe:

Number of Emergency Food boxes distributed: ____Weekly ____Monthly

GENERAL QUESTIONS:

Storage:

____Dry Storage ____ Refrigeration ____Freezer

Please describe your storage area- shelving, square feet of storage space, amount and size of refrigerators/freezers.

What percent of your clients are considered low-income (REQUIRED)? ______%

Has the percent of your budget for food increased or decreased in the last 6 months?

If yes, how much: ______

Describe your inventory control procedures (First in first out, order on need basis, etc.):

Does your agency prefer: ____Pick-up ____ Delivery

If delivery, do you prefer: ____Weekly ____Monthly ____Other:______

Does your agency understand that the Shared Maintenance Fees cannot be passed on to program participants? ____ Yes ____ No

Are you a member of any other Food Bank(s)? ____Yes ____No

Check the range that best describes the number of people that you serve:

____0-50____200-400

____51-200 ____401-500 ____Other

What is your geographic service area?

Describe how you promote your program within the community?

What are your hours of operation?

What is your verification process? Who decides who is eligible to receive assistance?

Please provide the verification guidelines for your program.

Describe any restrictions placed on those people to whom your agency provides food assistance.

Does your agency accept referrals from the other organizations? ____Yes ____No

If Yes, from whom: ______

IMPORTANT INFORMATION:

Authorized Shoppers (3 maximum) ______

______

______

Send Financial Documents to:

Name: ______

Address: ______

______

Phone: ______(If different than agency phone number)

Send email notices to:

Name: ______

Email address: ______

______

(Signature of Site Coordinator/Director)(Date)

Approved by:

______

(Agency Relations Coordinator, NEIFB) (Date)

______

(Director of Programs, NEIFB) (Date)

LETTER OF AGREEMENT

Date:______

Agency ID:______Agency:______

Mailing Address:______

The undersigned authorized agent of ______

(Name of Organization)

hereby warrants that during active membership, he/she will receive assorted foods from Northeast Iowa Food Bank. Said agent further warrants that the product received will be duly inspected upon delivery, and found to be fit for human consumption.

It is further agreed between said organization and the Northeast Iowa Food Bank that the organization agrees to comply with the following criteria and guidelines for participation in the Northeast Iowa Food Bank:

  1. Must be an established 501 © 3 charity organization, with an established program that has been operating under tax exempt status for 6 or more months, or meet criteria for church status.
  1. May not be a private foundation, even if it has 501 © 3 exemption status.
  1. Must be an organization or agency serving the needy, ill, or infants (minor children). At least 51% of the persons served must be low income.
  1. Must adhere to operate the program in accordance with Part 251 and, as applicable, Part 250 of federal regulations; USDA Title 7, Chapter 2.
  1. FOR PANTRIES ONLY: In accordance with USDA requirements, member pantries MUST have all clients fill out the TEFAP Eligibility Form. This form must be retained on file by member pantry. Clients need only to fill out the form once per year.
  1. Must either (a) serve food directly to its clients in the form of meals consumed on site or (b) provide emergency food boxes.
  1. Must not sell, trade or barter food directly or gain a profit by charging for meals via congregate meals programs or for food assistance via emergency food programs.
  1. Must keep accurate records of individuals served and have established procedures for the distribution of food. Monthly reports must be submitted to the Northeast Iowa Food Bank. If reports are not received for 3 months, the agency will be placed on product hold until all reports are received. If reports are not received for 6 months, agency membership will be terminated.
  1. Must notify the Food Bank if the program changes location or personnel or undergoes any significant changes in service.
  1. Must allow the Food Bank to monitor the program regularly, including authority to check records and inspect the facility. Comply with Health Department inspections if required by County Health Departments. Authorized monitoring will include unannounced site visits by Northeast Iowa Food Bank staff or authorized volunteers. If an agency refuses said visits, the agency will placed on product hold until the Northeast Iowa Food Bank is allowed to complete a site visit.
  1. Must provide transportation to pick up food. If this is not possible, delivery service is available at no cost to the agency with a minimum order of 20 cases (once a month to counties outside Black Hawk). Beginning in Spring 2015, a delivery fee of $0.10/lb. will be assessed to agencies who do not have volunteers on hand to unload deliveries.
  1. Must have adequate refrigeration and storage space to insure services provided.
  1. Must be agreeable to (a) supporting the operation of the Northeast Iowa Food Bank by making a per pound handling fee contribution for foods received, and/or (b) accepting food designated as “surplus” for no donation. Handling fees cannot be passed on to programs participants.
  1. The Northeast Iowa Food Bank reserves the right to prioritize the distribution of product to those agencies that serve high populations of ill, infant or needy individuals. If the organization is receiving USDA commodities from the Northeast Iowa Food Bank, the organization must be distributing the products to individuals at or below 185% of the poverty guidelines.
  1. The product is accepted “as is.”
  1. Northeast Iowa Food Bank, the original donor, and Feeding America offer no express warranties in relation to the product.
  1. Food Bank member agency will utilize employees or volunteers having sufficient training, experience and expertise in evaluation, handling, preparation and distribution of donated items. Member agencies must have one staff member trained in proper food safety guidelines and best practices, and provide
  1. documentation of this training to the Northeast Iowa Food Bank. The Northeast Iowa Food Bank will provide opportunities for certification to agencies without certified individuals.

Member agencies must have one staff member complete Civil Rights training annually. The Northeast Iowa Food Bank will provide this in conjunction with Food Safety training and the annual conferences. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: .

  1. Organization releases the original donor, Northeast Iowa Food Bank, and Feeding America from any liability resulting from the conditions of the donated food and further agrees to indemnify and hold Northeast Iowa Food Bank, the original
  1. donor, and Feeding America free and harmless against any and all liabilities, damages, losses, claims, causes of action and suits of law or inequity or any obligation whatsoever arising out of or attributed to any action of said Organization or any personnel employed by said Organization in connection with its storage and use of the donated food. (Iowa Code Chapter 672.1, Subsection3)

This agreement may be modified as deemed necessary by the Northeast Iowa Food Bank and may be terminated for any reason by either party upon 30 days written notice.

______

(Signature of Authorized Site Coordinator/Director) (Date)

______

(Agency Relations Coordinator, NEIFB) (Date)

______

(Director of Programs, NEIFB) (Date)

***If this form and any accompanying forms are not completed and returned to the Northeast Iowa Food Bank within three months of receipt, the agency will be placed on product hold until the agency’s file is completed.***