Form H-1535 is a form used to apply for an exemption from the individual shared responsibility provision of the Affordable Care Act. The form can be used by individuals who have religious objections to purchasing health insurance, or by individuals whose income is below the minimum threshold for mandatory coverage. In order to complete Form H-1535, you will need to provide detailed information about your religious beliefs and your income. You must also attach documentation supporting your application. If you are approved for an exemption, you will not be required to purchase health insurance. However, if you choose not to purchase health insurance and are later found to be in violation of the ACA, you may be subject to penalties. Please note that this form is only available in English at this time.
| Question | Answer |
|---|---|
| Form Name | Form H1535 |
| Form Length | 13 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 3 min 15 sec |
| Other names | department of agriculture form h1535, form h1535 march 2007, h1535 at, form h1535 |
Texas Department of |
Daily Meal Count and Attendance Record |
Form H1535 |
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Agriculture |
March 2007 |
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(Centers and Emergency Shelters)
Name of Contracting Organization
Name of Facility
Program No. (TX No.)
TX |
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– |
Month and Year
Centers: You may claim up to two meals and one snack or one meal and two snacks. Emergency Shelters: You may claim up to three meals or two meals and one snack.
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Participant’s Name |
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Total Number of |
L |
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Program Participants |
P |
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S |
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E |
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R |
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Total Number of Program Staff Meals |
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Total Number of |
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I certify that the information on this form is true and correct to the best of my |
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Page |
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of |
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knowledge and that I will claim reimbursement only for eligible meals served to |
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Date |
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eligible participants. I understand that misrepresentation may result in prosecution |
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under applicable state or federal statutes.