Texas Department of Form H1579

Agriculture March 2010

Request for Emergency USDA Foods

Requesting Agency:
Agreement No. Address

Area Code and Telephone No. Fax Area Code and Telephone No.

E-mail Address

Name of Authorized Representative (Please Print)

Signature of Authorized Representative Date

Reason for request:

Will agency be preparing meals for recipients? Yes No Will agency be distributing USDA foods to households?
If yes, please complete the following: Yes No
Number of people to be served: If yes, please complete the following:
Period of time USDA foods are requested: Areas included in request:
Number of sites providing meal service Number of households affected
Time period of distribution
Methods of distribution

Please provide the location of sites for prepared meals or distributed food. Attach additional sheets if necessary.
Name of site Type of site: Prepared meals
Address Distribute USDA Foods
Name of site Type of site: Prepared meals
Address Distribute USDA Foods
Name of site Type of site: Prepared meals
Address Distribute USDA Foods

If requesting specific foods, please list below:

Commodity Code Number of Units Commodity Name

TDA Authorization Name of TDA Representative

Title

Signature–TDA Representative Date