H1625-A - Square Meals

Instructions - Income Eligibility Guidelines for Determining Free and Reduced-Price Benefits
(H1625-A)
Contracting entities must give this form to Program participants annually and potential participants as
needed. This form must be provided at the same time as the CACFP Meal Benefit Income Eligibility
form, and as requested.
Make additional copies as needed or download Form H1625-A by accessing the Texas Department of
Agriculture (TDA) website at http://www.squaremeals.org.
Form Retention
Keep Form H1625-A for three years from the end of the program year. Exception: If audit findings,
claims or litigation have not been resolved by the end of the retention period, all forms and records must
be retained until all issues are resolved.
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Form H1625-A
Texas Department of
Agriculture
June 2016
Ingresos máximos para determinar
la elegibilidad para el programa de nutrición
1 de julio de 2016 - 30 de junio de 2017
Income Eligibility Guidelines
for Determining Free and Reduced-Price Benefits
July 1, 2016 - June 30, 2017
FAMILY
SIZE
1
2
3
4
5
6
7
8
For each additional
family member add:
ANNUAL
MONTHLY
TWICE MONTHLY
REDUCED
REDUCED
REDUCED
$21,978
$1,832
$916
$846
$423
$29,637
$2,470
$1,235
$1,140
$570
$37,296
$3,108
$1,554
$1,435
$718
$44,955
$3,747
$1,874
$1,730
$865
$52,614
$4,385
$2,193
$2,024
$1,012
$60,273
$5,023
$2,512
$2,319
$1,160
$67,951
$5,663
$2,832
$2,614
$1,307
$75,647
$6,304
$3,152
$2,910
$1,455
$642
$321
$296
$148
$7,696
BI-WEEKLY
REDUCED
WEEKLY
REDUCED
Children from households whose incomes are at or below the levels
shown above, or who receive Temporary Assistance for Needy
Families (TANF) or Supplemental Nutrition Assistance Program
(SNAP) benefits, are eligible for free or reduced-price meals.
Los niños de hogares con ingresos iguales o menores a los niveles indicados
anteriormente, o que reciben Asistencia Temporal para Familias Necesitadas
(TANF), ayuda del Programa Suplementario de Asistencia Nutricional (SNAP),
o del Programa de Distribución de Alimentos en Reservaciones Indígenas
(FDPIR) califican para recibir comidas gratuitas o a precio reducido.
Adult Day Care participants whose household incomes are at or below
the levels shown above, or who receive Medicaid, Supplemental
Security Income (SSI) or SNAP benefits, are eligible for free or
reduced-price meals.
Las personas que participan en programas de Cuidado Diario para Adultos
cuyos ingresos familiares son iguales o por debajo de los niveles indicados
anteriormente, o que reciben Medicaid, Seguridad de Ingreso Suplementario
(SSI), TANF, o beneficios de SNAP o FDPIR califican para recibir comidas
gratuitas o a precio reducido.