PURPOSE

To serve as primary documentation for Department of Aging and Disability Services (DADS) Home Delivered Meals (HDM) providers to summarize and report the total number of Older Americans Act (OAA) Nutrition Services Incentive Program (NSIP) eligible meals. DADS HDM providers must use Form 2071 to report Title XX meals, as well as other NSIP eligible meals if they are Title XX-Only providers. Common providers must use Form 2071 to report Title XX meals to the DADS Contract Manager. Common providers will follow procedures provided by their Area Agency on Aging (AAA) for reporting AAA and other NSIP eligible meals.

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

PROCEDURE

When to Prepare

Complete Form 2071 monthly.

Number of Copies

Complete an original and one copy.

Transmittal

Submit the original Form 2071 to the DADS contract manager. Retain a copy for your files.

Supply Source

This form must be printed or downloaded from the DADS website at http://www.dads.state.tx.us/handbooks/ccpfm/forms/index.asp.

Form Retention

Maintain a copy of each Form 2071 submitted to your DADS contract manager according to the terms of your contract.

DETAILED INSTRUCTIONS

Contractor Name — Enter the legal name of the HDM contractor.

Vendor No. — Enter the vendor number. If your agency has multiple contracts in a single region, please complete a separate Form 2071 for each vendor number. If your agency has multiple contracts in different regions, please submit each Form 2071 to the appropriate DADS contract manager.

Mailing Address — Enter the complete mailing address for your contract, including city, state and ZIP code.

Telephone No. — Enter the phone number for your agency. Please include the area code.

Do you contract with an AAA? — Enter the appropriate response to the question regarding whether you contract with an AAA.

If "Yes," what is the name of the AAA? — If you contract with an AAA, enter the name of the AAA.

Report Date — Enter the date the report is completed.

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

Eligibility Criteria — Use this section to determine which meals meet the eligibility criteria for OAA NSIP funds. All meals reported as OAA NSIP eligible must meet the eligibility criteria described on Form 2071.

Eligible Meals — Use this section to report the total number of OAA NSIP eligible meals provided during the service month.

Total No. of Title XX Meals — Enter the total number of Title XX meals provided by your agency during the service month. This figure should reflect only Title XX meals. Title XIX (CBA) meals are not eligible for OAA NSIP funds.

Total No. of Other NSIP Eligible Meals — Enter the total number of other NSIP eligible meals provided by your agency during the service month. This space is used by Title XX-only providers. If you have a contract with an AAA, you must report your other NSIP eligible meals to your AAA.

Certification — Use this section to certify the figures reported.

Certified By (Signature) — The agency representative signs to certify the report.

Date — The agency representative enters the date of signature.

Printed Name — The agency representative types or prints his or her name.

Title — The agency representative enters his or her job title.