SR 12-08 Dated 05/12

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revisions to DFA Form 778, Authorized Representative Declaration, and its associated instructions.

DESCRIPTION OF REVISIONS MADE TO DFA FORM 778

DFA Form 778, Authorized Representative Declaration, is a 1-page, double-sided form used to allow an applicant or recipient of any DFA program or service to name an authorized representative (AR) who will act on their behalf. The form also allows the applicant or recipient to indicate which responsibilities they wish the AR to fulfill. This form was revised to increase clarity and ease of use, as requested by the Error Reduction Advisory Team (ERAT) and Field Operations.

·   The language was simplified throughout the form to bring it closer to an 8th grade reading level.

·   The CLIENT'S SIGNATURE section has been moved from the back of the form to the front of the form, and the AUTHORIZED REPRESENTATIVE INFORMATION section has been moved to the back. This change was made in response to feedback from the field that clients tend to fill out the AR portion with their own information, as this section was presented first on the form.

·   A field to collect the AR’s date of birth (DOB) has been added to this form. This information is optional, meaning the AR does not have to provide their DOB unless they choose to. The AR assignment cannot be rejected by Department staff if the AR’s DOB is not provided. This field was added to verify if an AR is also a client. If the AR is a client, information on the AR form can be cross-matched with information in the system to identify discrepancies.

·   A field to collect an agency name has been added to the form, in the event that an AR works for an agency. Knowing the name of the agency is helpful when trying to contact the AR and provides a basis for understanding the type of relationship between the AR and the client. However, per current policy, the agency cannot act as the authorized representative. The authorized representative must be an individual person.

·   Text has been added to notify the prospective AR of the following federal requirements:

- An AR must show proof of identity.

- A person who has been disqualified for a program violation cannot act as an AR unless there is no one else suitable to represent an individual.

- DHHS has the authority to disqualify a person from being an AR if it is determined that they are not acting in the best interest of the household they are assisting.

- If an AR for a Food Stamp recipient in a drug and alcohol treatment center or other group living arrangement gives erroneous information which leads to an over-issuance of benefits, those benefits will be recouped from the treatment center or group living arrangement group, not just the resident that the AR represents.

Note: The right of an individual to act as an AR for an applicant or recipient may not be terminated by DFA for any reason except at the direct request of the individual, per current policy at FAM/FSM 111.11, Abuse by AR or Failure of an AR to Perform Their Duties, and AAM 111.01, AR Acting in Place of the Individual. This means that the assignment of an Authorized Representative and their duties never expire, thus DFA Form 778 is retained as a permanent part of the case record. Contacting the client or the Authorized Representative at time of redetermination to obtain a newly signed DFA Form 778 is not expected and is not mandated by policy. Similarly, updating AR contact information at redetermination is also not mandated by policy. Once an AR has been assigned by the applicant or recipient, it is that individual’s right to retain that AR if they desire, and per policy, for as long as they like, and it is that individual’s responsibility to notify the Department in writing of any changes. The Department, per current policy, must only contact the individual about the choice of AR if the AR is not acting in the individual’s best interest.

The instructions for DFA Form 778 have been updated accordingly.

The standing stock of current and older versions of DFA Form 778, and any translated versions, must be used until the stock has been depleted, at which point contact:

·   the DHHS Warehouse in the usual manner, via the Quarterly Forms Order (QFO), for additional supplies of the English version; or

·   the Supervisor of the DFA Policy Development Unit for copies of the Bosnian and Spanish versions of this form. The Spanish and Bosnian versions of this form are being retranslated and will be released under separate cover at a later date.

IMPLEMENTATION

District Office staff must deplete the old version of DFA Form 778, and any translated versions, before the new version is printed. Once the current supply of DFA Form 778 is exhausted, the new version will be available from the DHHS warehouse in the usual manner, via the QFO. The form is also available electronically on the DHHS website and internally, for Department staff only, on the Lotus Notes Family Services Database.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned or needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective July 2, 2012. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Forms Manual.

DFA/LRB:s