Enter the following information for each of the donated USDA Foods lost or destroyed. DO NOT ENTER WITHOUT SALES ORDER NUMBER. Format Example - 5000432726-000100. Underlined portion not necessary.

Submit applicable evidence and documentation relating to the loss, such as:

1. Pictures of damaged items
2. Condemnation Certificate by health official
3. Destruction Certificate ( must include when, where, how USDA Foods were destroyed, and by whom)
4. Temperature Logs for freezer or cooler
5. Police Report, if theft of vandalism was involved
6. Fire Department Report, if loss was due to fire
7. Extermination Records, if loss was due to infestation
8. Refrigeration repair records, if loss due to failure

Please verify all the information on the previous page you are about to submit is complete and notated correctly before submitting.