Form H4529 Texas Department of Agriculture Authorization to Transfer USDA Foods July 2016 USDA Foods to be Transferred * Location of USDA Foods Date USDA Foods USDA Material Number of (on-site, state-contracted Received at Number or End Description Units warehouse, commercial Warehouse or Food Product Code distributor, etc.) Bank *If foods are for National School Lunch Program (NSLP), TDA will complete this column. Transferring Contracting Entity (CE) CE’s ID CE’s Name Address Date Area Code and Phone Number Area Code and Fax Number Email Address Authorized Representative’s Name Authorized Representative’s Signature (print or type) Receiving Contracting Entity (CE) CE’s ID CE’s Name Address Date Area Code and Phone Number Area Code and Fax Number Email Address Authorized Representative’s Name Authorized Representative’s Signature (print or type) For NSLP Only. I certify that the product is on hand and is in good condition. Warehouse Name Date Warehouse Representative’s Name (print or type) Warehouse Representative’s Signature For TDA Use Only. I approve this transfer. Yes ______ No _____ Allocation Name Date Completed TDA Representative’s Name (print or type) TDA Representative’s Signature
Texas Department of Agriculture Authorization to Transfer USDA Foods Form H4529 July 2016 USDA Foods to be Transferred USDA Material Number or End Product Code Number of Units Description Location of USDA Foods (on-site, state-contracted warehouse, commercial distributor, etc.) * Date USDA Foods Received at Warehouse or Food Bank Transferring Contracting Entity (CE) *If foods are for National School Lunch Program (NSLP), TDA will complete this column. CE’s ID CE’s Name Address Date Area Code and Phone Number Area Code and Fax Number Email Address Authorized Representative’s Name (print or type) Authorized Representative’s Signature Receiving Contracting Entity (CE) CE’s ID CE’s Name Address Date Area Code and Phone Number Area Code and Fax Number Email Address Authorized Representative’s Name (print or type) Authorized Representative’s Signature For NSLP Only. I certify that the product is on hand and is in good condition. Warehouse Name Date Warehouse Representative’s Name (print or type) Warehouse Representative’s Signature For TDA Use Only. I approve this transfer. Yes ______ No _____ Allocation Name Date Completed TDA Representative’s Name (print or type) TDA Representative’s Signature