Dear Friend:

Thank you for your interest in America's Second Harvest of Kentucky's Heartland (Second Harvest). Our mission is to provide food and personal products to non-profit and church based non-profit 501C(3) organizations that serve the needy, ill or infants. You will find our applications and policies enclosed. Please make sure that you fill in all applicable blanks including all required signatures before returning the application(s) to Second Harvest.

The final page of the application/agreement is in reference to your tax-exempt status under section 501C(3). We must receive either a copy of your 501C(3) letter from the IRS or a letter from the leader of your church on church stationary (see the explanation on that page of what is required in the letter).

Also included in this site is a separate application that must be completed in order to participate in the USDA commodity program. Please review that package in the event you may be interested in distributing the government commodities through your agency. If interested, please complete the separate USDA application.

Please feel free to call 270-769-6997 if you have any questions concerning Second Harvest or this application.




Sincerely,

Gary Miles
Executive Director
America's Second Harvest
of Kentucky's Heartland


ENCLOSURE

APPLICATION FOR MEMBERSHIP

Please note: Completion of this application does NOT guarantee membership.
We reserve the right to refuse membership to programs not meeting our criteria.

SECTION 1: GENERAL INFORMATION

(to be filled out by all applicants)

Agency Name ______________________Date _______________
Agency Address_________________________________________________
Mailing Address (if different) ______________________________________
Parent and/or Affiliated Organization_________________________________
Agency Manager _________________________________________________
Contact Person(s)_________________________________________________
Telephone (Agency) _______________ (Manager) _____________________
Persons Authorized To Pick Up Product _______________________________
_____________________________________________________________________
Do you have federal tax exempt status under 501C(3)? Yes_______ No_______
(attach a copy of your IRS determination letter or church qualifier form)
Federal Employee Identification Number _______________________________
Describe you general program in the space below (or attach agency brochure):
What are your funding sources?_______________________________________
Where will funds to pay shared maintenance come from?___________________
When did you begin providing services described above? ___________________


SECTION II: FEEDING PROGRAM INFORMATION

Check category or categories describing your program:


(A) _____ Food Pantry (providing groceries to the needy, ill or infant).
(B) _____ Residential Program (cooking and serving meals to registered clientele: including Day Care, Detox, Half-way homes, Group homes, Day Activities Programs, etc.)
(C) _____ Soup Kitchen (cooking and serving meals to walk-in guests on a regular or occasional basis).
** DEPENDING ON WHICH CATEGORIES CHECKED, PLEASE COMPLETE THE FOLLOWING:**

(A) FOOD PANTRY

1. CONTACT PERSON(S): _____________________________________
2. HOURS: What days/hours are you open to help people?:
Monday _______________ Wednesday_____________ Friday_________________ Sunday________________ Tuesday ___________________ Thursday___________________ Saturday___________________
3. Approximately how many families per month are you now serving?__________
What ages?________ How many would you like to serve?_____
4. What products do you provide or plan to provide (check all applicable):
____canned goods ____frozen foods _____dry goods (rice, cereal, etc.)
____perishables (dairy, fresh fruit, etc.) _____meats
____(fresh/frozen)____non-food groceries (when available)
How many days supply of food is provided to each person/family? _____
5.What geographical areas do you serve?___________________________

Is your services limited to these areas/neighborhoods?_________________

6. What are your eligibility guidelines? _____________________________ ___________________________________________________________
7. Do you have a refrigerator? _________ freezer? ________
8. Present sources of food: _________% donated (includes food bank) ________% purchased

9. Do you accept walk-ins? _________ Referrals? _________ (from which sources?): _____________________________________________________
10. What proof of need do you ask for (if any)?_______________________

11. Do you (or do you plan to) keep records for the people you help? _____ What will (does) the record include? ______________________________________________ __________________________________________________________
12.Do you require people to attend church services or work in exchange for product? __________________________________________________

13. MAY WE REFER INDIVIDUALS WHO CALL SECOND HARVEST FOR HELP TO YOUR PROGRAM? ____________________________________________________


(B) RESIDENTIAL PROGRAMS (Youth Camps/Day Care/After School Programs, Etc.)


1. How many individuals are in your program?________ Ages:________

2. Which meals do you serve?:

____breakfast ____lunch ____dinner ____snacks
3.What days do you serve meals?________________________________

4. Do you have a room/board or program fee? ___ If yes, how much?_____
5. Are you licensed? ______ If so, by whom? ___________ Lic# _______

6. What percentage of your clients are low-income and/or eligible for government aid? _______

(C) SOUP KITCHENS/FEEDING PROGRAMS

1. How many individuals served per meal? _____ What ages? __________
2.Which meals do you serve? ____breakfast ____lunch ____dinner ____snack

3. Do you charge for meals? ____ If yes, how much? _______________ Do you ask for donations from meal recipients? _____ If yes, describe your donation procedures:

4. What percentage of your guests are low-income? ___________________

5.Do you have a health certificate from the local Board of Health, licensing you to serve public meals?_______ Certificate #: __________________
6. Do you have a refrigerator? _______ freezer? ______
7. What percentage of your food is donated (including food bank)? ______ purchased? ______

SECTION III (to be completed by all applicants)

Please provide the name of one social service agency or church in your neighborhood that is familiar with your program which we may contact as a reference:

NAME OF AGENCY: _____________________________________
NAME OF CONTACT:____________________________________
ADDRESS: _____________________________________________
TELEPHONE NUMBER ( )_______________________________
Name of person completing application: ______________________
Position:______________________ Date:_______________
How did you hear about America's Second Harvest of Kentucky's Heartland? __________________

AMERICA'S SECOND HARVEST of KENTUCKY'S HEARTLAND AGENCY AGREEMENT FORM


Agency Name_________________________________Date_______________

Agency agrees to and will comply with the following criteria of a recipient agency of America's Second Harvest of Kentucky's Heartland. (Second Harvest):

  1. Must have a 501C(3) tax exempt status with the Internal Revenue Service (IRS) or be a 501C(3) equivalent (churches). To be valid a copy of the IRS letter or a church qualifier letter (churches see attached requirement) must be attached to this signed agreement.
  2. Must not sell, transfer, barter or offer for sale the items supplied by the food bank in exchange for money, property or services, or otherwise allow the items to re-enter commercial channels.
  3. Must be an agency that serves the needy, ill, or infants.
  4. Must serve food and/or grocery products directly to its clients in the form of meals or distributed through a charitable food pantry serving the needy, ill or infants.
  5. Must have adequate refrigeration and storage space to ensure the wholesomeness of the food until used, and/or redistributed.
  6. Must be licensed by the State and/or City as a food service establishment according to the service it provides.
  7. Must be agreeable to monitoring by the food bank representatives.
  8. Must be agreeable to supporting the operation of Second Harvest with shared maintenance of up to .14 cents per pound for product received.
  9. Must maintain a file of all Second Harvest receipts for one year.
  10. Must not deny access to donated product on the basis of race, creed, national origin, religious affiliations, sex, sexual preference, age, or handicap.
  11. Must agree to abide by all Second Harvest policy guidelines and procedures for distributing donated product.
  12. Understands that violation of Second Harvest policy guidelines and procedures may result in the termination of Second Harvest membership.

Director's Signature: __________________________________________

Signature of Church Pastor/Priest/Minister (churches only): __________________________________________

Approved for Membership: ________________________________

Executive Director
America's Second Harvest of Ky's Heartland

OTHER APPLICATION SUBMISSION REQUIREMENTS

  1. Please provide with your membership application a copy of the IRS letter stating that you are in fact a non-profit organization under Section 501C(3) of the U.S. Tax Code.
  2. A copy of your latest Health Department inspection, if applicable.
  3. Any brochures or flyers which explain your program (if available).

NOTE: If your agency is an independent church, you may substitute the following for 1) above:

A letter on church stationary or letterhead from the President or CEO of your church that explains how your church meets the following characteristics of a church:

  1. A distinct legal existence.
  2. A recognized creed and form of worship.
  3. A definite and distinct ecclesiastical government.
  4. A formal code of doctrine and discipline.
  5. A distinct religious history.
  6. A membership not associated with any (other) church or denomination.
  7. A complete organization of ordained ministers ministering to their congregations.
  8. Ordained ministers elected after completing prescribed courses of study.
  9. A literature of its own.
  10. Established places of worship.
  11. Regular congregations.
  12. Regular religious services.
  13. Sunday schools for religious instruction of the young.
  14. Schools for the preparation of its ministers.

Please note that the IRS objective in employing this list of characteristics is to screen out what essentially are tax-avoidance schemes. The IRS recognizes, however, that not all legitimate churches will necessarily meet all 14 criteria (for example, an independent church, which is not part of a larger denomination, may not have a school for preparing ministers, a Friends (Quaker) Meeting won't have a minister, etc.)

Your letter needs to establish that your organization is clearly a church within the spirit of the IRS guidelines.



FOOD RECEIPT AND INSPECTION

The undersigned, authorized agent of ________________________, hereby assures America's Second Harvest of Kentucky's Heartland that all product received from Second Harvest will be inspected in a timely and proper manner upon delivery to said organization. If product is found unfit for human consumption, said organization shall notify Second Harvest immediately for corrective action.

It is further agreed between said non-profit 501C(3) organization, (hereafter referred to as Organization) and Second Harvest that:.

  1. All product is received "as is."
  2. Second Harvest and the original donor expressly disclaim any warranties of marketability or fitness for any particular use.
  3. There have been, nor are there at any time, any express warranties in relation to donations of product.
  4. Said organization releases both the original donor and Second Harvest from any liability resulting from the use of Second Harvest product.
  5. Said organization agrees to indemnify and hold the original donor and Second Harvest free from any and all liabilities, damages, losses, claims, and causes of action and suits of law or in equity 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 donated product.
  6. If any product acquired from Second Harvest is found to be used unlawfully or for any type of profit making endeavor, said organization will be immediately and unconditionally removed from their membership for an indefinite period of time. Further, Second Harvest is required to notify proper authorities in the event of unlawful use of donated product.

I have read and understood the above rules and regulations as well as the penalties for violations of such. I state that I am an authorized agent of the aforementioned non-profit 501C(3) organization and state that said organization and its agents, employees and volunteers will comply with Second Harvest policies concerning donated product.


____________________________
Printed Name
____________________________ _________________
Signature Date