Organization Name(*)

Your Name(*)

Your Email(*)

County(*)

Site Address(*)

Mailing Address if different

Name of Principal Officer (must be the highest authority in the organization, who is responsible for any and all actions of the organization) (*)

Best time to contact(*)

Facility Information(*)

Type of Program(*)

Average Number of Households Served (Estimate if this is a new program)(*)

Average Number of Individuals Served (Estimate of this is a new program)(*)

Are you interested in starting a:

Does someone on your staff have a Food Handlers Certification?(*)

If no, would you be interested in a group training and certification session. (Programs preparing food must have a person on site during meal preparation who has a Safe Food Handlers Certification)

Days of Operation(*)

Frequency of Operations(*)

Comments: Use this space for any additional information about your organization.

Requirements: The Agency agrees to abide by the policies, procedures, and record keeping requirements of the Tri-State Food Bank, Inc.(*)

IRS Eligibility Requirements: The Agency agrees that it meets the IRS eligibility requirements for the receipt, transfer, and use of donated products (food and non-food) under section 170(e)(3) of the IRS code, (that it is incorporated as a 501(c)3 Non-profit corporation or is considered a “church” as defined by the IRS.(*)

Purpose of Incorporation and Service: The Agency agrees that it is incorporated to serve the ill, needy and/or infants (minor children 0-18 years old). The Agency also agrees that it is not incorporated for a purpose unrelated to serving the ill, needy and/or infant (minor children) (such as publication of a non-profit periodical providing information to members.)(*)

Distribution without charge: The Agency agrees that it will distribute the donated products (food and non-food items) obtained from Tri-State Food Bank, Inc. free of charge (monetary, volunteer hours, services or otherwise.)(*)

Recipients of Distributed products: The Agency agrees that it will only distribute donated products to recipients who qualify as ill, needy and/or infant (minor children 0-18 years old) as defined in IRS code section 170(e)3. The Agency also agrees that it will not distribute donated products to people who do not qualify to receive the products as defined in IRS Code section 170(e)3.(*)

Use of Donated Products: The Agency agrees that it will not sell or use donated products in exchange for money, other property or services, including using donated products for the purpose of fundraising programs and events. The Agency also agrees that it will comply with the restrictions on the use and transfer of donated property, as described in IRS Tax Code Section 170(e)3 and any amendments to the Code(See the Federal Register/Vol. 47, No.21/Monday, February 1982/Rules and Regulations, pp. 4509-4512).(*)

Bartering, Selling and Fundraising: The Agency agrees that it will not barter, sell or use for fundraising purposes any donated products obtained from the Tri-State Food Bank, Inc.(*)

Area of Distribution: The Agency agrees that it will only distribute products received from Tri-State Food Bank, Inc. in the State and County where site is located.(*)

Record Keeping: The Agency agrees that it will maintain adequate books and records and accurately reflect the total amount of product received and distributed (or used), a description of the products and the date of its receipt. The agency also agrees to outline its procedure for determining that the final recipient of the product is ill, needy or infant (minor child, 0-18 years old). The Agency agrees that it will remit to TSFB the most recent monthly report, with complete and accurate information, by the 3rd (Indiana and Kentucky) and by the 15th (Illinois).(*)

Availability of Records: The Agency agrees to make its books and records, including but not limited to those which track the receipt and distribution of products obtained from the Tri-State Food Bank, Inc. and financial record keeping books available to the Tri-State Food Bank, Inc., with or without notice.(*)

Local, State and Federal Regulations: The Agency agrees that it will ensure the donated product conforms to any applicable provisions of the FDC and Cosmetic act (as amended), and any regulations that follow. The Agency also agrees that it will handle products, conforming to all local, state and Federal regulations, and will maintain current licenses as required by local, state and Federal regulations.(*)

Storage and Handling of Products: The Agency agrees that it will store, handle and distribute products consistent with the Federal Food, Drug and Cosmetic Act and any regulations that follow.(*)

Food Safety: The Agency agrees that at least one staff person be trained in food safety from a food safety training course approved by the Tri-State Food Bank, Inc. Approved trainings are Tri-State Food Bank, Inc. Food Safety Training Workshop, ServSafe Certification, National Restaurant Association Certification, and Food Handlers Card, or other approved safety training curriculums. The Agency also agrees that if it utilizes food provided by the Tri-State Food Bank, Inc. to make meals, their key food service program staff are required to meet local commercial food safety standards.(*)

Donor Stipulations: The Agency agrees that it will adhere to any donor stipulations placed on donated products.(*)

"As Is" Condition: The Agency agrees that it will accept all products received from the Tri-State Food Bank, Inc. in “as is” condition.(*)

Shared Maintenance, Transportation and Value Added Processing Fees: The Agency agrees to pay any applicable Shared Maintenance and/or handling fees (Value Added Processing, Delivery Charges, Transportation fees) for the products received from the Tri-State Food Bank, Inc. by the 15th of each month. (*)

Purchased Product: The Agency agrees that if it should choose to purchase non-donated product then it may pay extra charges and costs associated with that product.(*)

Discrimination: The Agency agrees that it will not engage in discrimination, in the provision of service, against any person because of race, color, citizenship, religion, sex, national origin, ancestry, age, marital status, disability, sexual orientation including gender identity, unfavorable discharge from the military or status as a protected veteran.(*)

On-Site Inspections: The Agency agrees to allow representatives of Tri-State Food Bank, Inc., donors and government agencies to inspect and audit all facilities and vehicles where products received from the Tri-State Food Bank, Inc. are received, stored and distributed, with or without notice.(*)

Authorized Agent: The Agency agrees to have only an authorized agent(s) pick-up or receive products from Tri-State Food Bank, Inc. The Agency also agrees to make known to the Tri-State Food Bank, Inc. a list of authorized agents and contact Tri-State Food Bank, Inc. when a change is made to that list.(*)

Access to One Feeding America Member Food Bank: The Agency agrees that it will only receive food from the Tri-State Food Bank, Inc. and no other Feeding America Member Food Bank.(*)

Liability Release Form: The Agency agrees to execute and submit to Tri-State Food Bank, Inc. the Liability Release Form, and any other liability release forms that Tri-State Food Bank, Inc. may require at any time.(*)

Active/Inactive Agency Designation: The Agency agrees that it will obtain products from Tri-State Food Bank, Inc. at least every 180 days to be deemed an Active Agency. If the Agency becomes inactive, then the Agency will not be allowed to obtain products from Tri-State Food Bank, Inc. The Agency agrees that it will complete the agency application process again, prior to being reinstated as an Active Agency and allowed to obtain products from Tri-State Food Bank, Inc. again.(*)

Termination of Agency Agreement: The Agency agrees that either Agency or Tri-State Food Bank, Inc. can terminate this agreement, with or without cause, at anytime.(*)

Corrective Action, Grievance and Termination Policy: The Agency agrees to execute and submit to Tri-State Food Bank, Inc. the Corrective Action, Grievance and Termination Policies documentation when applicable.(*)

Multiple Locations and Sub-distribution: The agency agrees that it will only receive and store product from Tri-State Food Bank, Inc. at multiple locations if: 1. all locations individually meet the requirements of this agreement, 2. have been inspected and, 3.are approved by Tri-State Food Bank, Inc. prior to receiving and distributing food. The agency is not allowed to sub-distribute donated product to any organization, agency, partner, or entity other than a qualifying client.(*)

TRI-STATE FOOD BANK, INC. Agency Handbook: The Agency agrees that it will abide by the rules, regulations and guidelines at all times set forth by Tri-State Food Bank, Inc. Agency Handbook.(*)