USDA DONATED FOOD COMPLAINT FORM INSTRUCTIONS

							FDP FORM 26
Rev. 1/04

                    USDA DONATED FOOD COMPLAINT FORM & INSTRUCTIONS

STATE: ALABAMA                                                                   COMPLAINT #____________

Please complete in as much detail as possible. This will assist us in determining which vendor supplied the
commodity. NOTE: If the food is not a canned item, you will not be able to complete the can code section. Be as
specific as possible on describing the problem or complaint. In the number of cases unfit for consumption section,
list the number of cases you feel are unfit for consumption and that will need to be dispose of. Please send a
sample of any foreign material found in a commodity item with the complaint.

NAME OF THE RECIPIENT AGENCY:___________________________________________________________

ADDRESS: __________________________________________________________________________________
                  P.O. BOX OR STREET

CONTACT PERSON:__________________________________________TITLE: __________________________

TELEPHONE: __________________________________ DATE COMPLAINT FILED:________/_______/_____

COMMODITY: _________________________________ DISPOSTION # ________________________________

CONTRACT #: _________________________________ ND #: ________________________________________

LOT #: ________________________________________ BOX #: _______________________________________

CAN CODE: ___________________________________ PACK DATE: __________________________________

DATE PRODUCT RECEIVED _____/_____/_________ SHIP DATE: ________/_______/__________________

VENDOR: ___________________________________________________________________________________

LOCATION OF PRODUCT: ____________________________________________________________________

AMOUNT RECEIVED: __________ AMOUNT USED: __________ BALANCE ON HAND: ______________

NUMBER OF CASES UNFIT FOR CONSUMPTION (YOUR JUDGEMENT): ___________________________

IS THE COMMODITY STILL BEING USED? YES                  NO    AMOUNT ON HOLD: ____________________

REASON FOR COMPLAINT: Seeking Replacement     For Information Only                     Isolated Incident
     Other Vendor Response  Notify Vendor, No Response Necessary

DESCRIPTION OF PROBLEM/COMPLAINT: _____________________________________________________




DO YOU WANT A RESPONSE TO THIS COMPLAINT?                        YES     NO

                                                        SIGNED_______________________________________
                                                                    (Name of person making this report)