Daily Meal Count And Attendance Record
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1Texas Department of
Form H1535
Daily Meal Count and Attendance Record
Agriculture
March 2007
(Centers and Emergency Shelters)
Name of Contracting Organization
Name of Facility
Program No. (TX No.)
Month and Year
TX
–
Centers: You may claim up to two meals and one snack or one meal and two snacks. Emergency Shelters: You may claim up to three meals or two meals and one snack.
Day
Date
Day
Date
Day
Date
Day
Date
Day
Date
Participant’s Name
Age
At
B
A
L
P
S
E
R At
B
A
L
P
S
E
R At
B
A
L
P
S
E
R At
B
A
L
P
S
E
R At
B
A
L
P
S
E
R
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
At
B
A
L
Total Number of
Program Participants
P
S
E
R
Total Number of Program Staff Meals
Total Number of Non-Program Meals
I certify that the information on this form is true and correct to the best of my
Page
of
knowledge and that I will claim reimbursement only for eligible meals served to
Signature—Center/Emergency Shelter Representative
Date
eligible participants. I understand that misrepresentation may result in prosecution
under applicable state or federal statutes.
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