Texas Department of Agriculture
Claim for Reimbursement Worksheet – Meals
Form H4502
April 2007
Contractor Program No. Month and Year
TX —
Number Breakfasts Number A.M. Snacks Number Lunches Number P.M. Snacks Number Suppers No. Evening Snacks
Date
Total First
Meals
Total
Second
Meals
Total First
Meals
Total
Second
Meals
Total First
Meals
Total
Second
Meals
Total First
Meals
Total
Second
Meals
Total First
Meals
Total
Second
Meals
Total First
Meals
Total
Second
Meals
Number At Risk
Afterschool Snack
Total First
Meals
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Totals
Transfer program participant meal information to the corresponding column for the appropriate program on the
Form H1532, Claim for Reimbursement – Food and Nutrition Division.
Form H4502
Page 2/04-2007
Administrative Costs Program Operation Costs
Date Name of Payee
Check
Number or
Cash
Receipt
Labor and
Fringe
Travel Other
Total
Administrative
Costs
Labor and
Fringe
Food
Purchases
Non-Food
Purchases
Other
Total
Program
Operational
Costs
Total
Credits
Total Total
Totals
