Effective Date: 
8/2005

Documents

 

Instructions

Updated: 8/2005

 

Purpose

To serve as primary documentation for Texas Health and Human Services Commission (HHSC) regional liaisons to summarize and report the total number of Older Americans Act (OAA) Nutrition Services Incentive Program (NSIP) eligible meals reported by Home-Delivered Meals (HDM) providers.

The reports are used to determine the allotment of OAA NSIP funds allotted to Texas. These funds are used to purchase of additional OAA eligible meals in the following Federal Fiscal Year (FFY).

 

Procedure

When to Prepare

Complete Form 2072 quarterly.

Number of Copies

Complete an original and one copy.

Transmittal

Submit the original Form 2072 to the designated state office staff, along with a copy of each Form 2071, Report of OAA NSIP Eligible Meals, submitted by each HDM provider in your region. Retain the copy for the regional files.

Form Retention

Maintain a copy of each Form 2072 until the OAA NSIP funds are allotted to Texas for the following FFY.

 

Detailed Instructions

Region No. — Enter the region number.

Regional Liaison — Enter the name of the regional liaison. The regional liaison is the person responsible for completing the aggregate report and the contact person for questions regarding the report.

Telephone No. — Enter the phone number for the regional liaison. Please include the area code.

Report Date — Enter the date the report is completed.

Service Month/Year — Enter the month and year that the OAA eligible meals are provided.

Eligible Meals — Use this section to report the total number of OAA NSIP eligible meals provided during the quarter. This should reflect all the NSIP eligible meals reported by the HDM Providers in the Region.

Total No. of Title XX Meals — Enter the total number of Title XX meals reported by HDM providers during the quarter. This figure should reflect only Title XX meals.

Total No. of Other NSIP Eligible Meals — Enter the total number of Other NSIP Eligible meals reported during the quarter. This space is used to report Other NSIP Eligible meals provided by Title XX-Only providers. Common providers must report their Other NSIP Eligible meals to their Area Agency on Aging (AAA.)

Certification — Use this section to certify the figures reported.

Certified By (Signature) — The regional liaison signs to certify the report.

Date — The regional liaison enters the date of signature.

Printed Name — The regional liaison types or prints his or her name.

Title — The regional liaison enters his or her job title.

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