Food Donation Pickup Log

Pick Date & Time *

Date

Time

Registered Partner Name *

Select Food Donor

List the Food Item: Name | Quantity | Weight

First

Middle

Last

First

Middle

Last

First

Middle

Last

First

Middle

Last

First

Middle

Last

First

Middle

Last

The following list of issues must be addressed before this donation can be submitted. *

This donation was intentionally created with no Qty/Weight.
This donation was created with Qty/Weight listed.

Select each box to cerity that the agency receiving the donated food product from the above location confirms that it was received and used in compliance with the following requirements: *

1. The agency is an Internal Revenue Code (IRC) §501(c)(3) tax exempt, U.S. nonprofit public charity or other organization qualified to receive tax-deductible contributions that serves infants, ill, or needy and is not a private foundation.
2. The agency has passed all applicable local and state health and safety inspections and all donated product will be maintained at a safe temperature as prescribed by all applicable laws/regulations.
3. The agency will indemnify and hold the donor harmless from losses and damages resulting from the agency’s mishandling of the of the donated product.
4. The agency is an independent contractor and has not, nor will not, represent it has any authority, expressed, implied, or apparent, to act on the behalf or as an agency of the Donor or FDC for any purpose.
5. The agency will maintain adequate books and records to show the disposition or use of the donated product, which will be made available to the Internal Revenue Service upon request.
6. The agency will carry adequate liability insurance that includes donated food products.
7. The donated product was not transferred in exchange for money, other property or services.

Signature of Senior Organization Representative

Food Donation Pickup Log

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