SR 22-35 Dated 12/22

STATE OF NEW HAMPSHIRE

DEPARTMENT OF HEALTH & HUMAN SERVICES – DIVISION OF ECONOMIC AND HOUSING STABILITY (DEHS)

Bureau of family assistance (bfa)

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This Supervisory Release (SR) releases:

•        The creation of BFA Form 63, Residence History, and its associated instructions.

•        Revision of BFA Form 77d, SNAP Information Sheet, and its associated instructions.

•       The creation of BFA Form 735, Profit and Loss Statement for Self-Employment, and its associated instructions.

•       The creation of BFA Form 737, Monthly Self-Employment Log, and its associated instructions.

•       The creation of BFA Form 745, Statement of Contributions, and its associated instructions.

•       Revisions to BFA Form 773, Certification of Continued Absence, and its associated instructions.

POLICY

There are no policy changes associated with this SR.

NEW HEIGHTS & NH EASY SYSTEMS PROCEDURES AND IMPLEMENTATION

All forms will be available on NH EASY and in New HEIGHTS for batching.

DESCRIPTION OF REVISIONS MADE TO FORMS

BFA Form 63, Residence History

This form has been developed to enable the Long Term Care unit to collect address history from applicants, which is necessary to determine county liability. The form has space for an applicant to provide up to 3 addresses (current and previous) along with move-in and move-out dates and the type of housing for each address. Applicants must provide residence history back to a point at which they were not receiving any type of housing subsidy. This form has been translated to Spanish and instructions have been created.

BFA Form 77d, SNAP Information Sheet

This form has been revised to contain more current and relevant information, as well as encourage the use of NH EASY. BFA Form 77d was previously a tri-fold brochure to be given to those interested in learning more about SNAP. The form is now a double-sided sheet containing information about how to apply, eligibility criteria, work requirements, using NH EASY, and current District Office locations and contact information. The Spanish version has also been updated accordingly. The previous version of form 77d was translated to Nepali; the Office of Minority Health and Refugee Affairs (OMHRA) has informed BFA that there is no longer a need for BFA forms to be translated into Nepali. The updated version of 77d will not be translated to Nepali and all previous Nepali versions are obsolete with the release of this SR and should be recycled.

BFA Form 735, Profit and Loss Statement for Self-Employment

This form has been developed for applicants and recipients of all programs of assistance to report income and expenses for self-employment when they have not filed a current tax return or their most recent tax return is not reflective of current and ongoing income. For consistency, all District Offices should begin using this form and discontinue the use of any unofficial profit and loss forms. This form has been translated to Spanish and instructions have been created.

BFA Form 737, Monthly Self-Employment Log

This form has been developed for applicants and recipients of all programs of assistance to report income and expenses related to self-employment for a 1-month period. For consistency, all District Offices should begin using this form and discontinue the use of any unofficial self-employment logs. This form has been translated to Spanish and instructions have been created.

BFA Form 745, Statement of Contributions

This form has been developed for applicants and recipients of all programs of assistance to verify information regarding contributions they receive. The form has a section to be completed by the contributor which includes space for their name and phone number, amount and frequency of contribution, whether it is a gift or a loan, whether the contribution will continue or not, and a signature and date. The bottom section of the form is to be completed by the client and includes space for their name and case number as well as a signature and date. This form has been translated to Spanish and instructions have been created.

BFA Form 773 Certification of Continued Absence

The requirements for FANF applicants to complete BFA Form 773 Certification of Continued Absence at application and again, if needed, after 30 days of continued absence, remains the same. The form was revised to provide clearer guidance to applicants on its completion, in an effort to reduce the number of forms that are completed incorrectly. The form now has a question at the top “Has the absent parent been out of the home for 30 days or more?” with a ‘Yes’ or ‘No’ for the individual to circle. The individual is then instructed to complete Section 1 if they answered ‘Yes’ or Section 2 if they answered ‘No’. The Spanish version, 773(Sp), has also been updated, along with the form instructions, 773(i). The Nepali version, DFA Form 773(Ne) is obsolete with the release of this SR, and any copies on hand should be recycled. Any printed copies of the current English and Spanish versions of Form 773 should be used up prior to printing the new versions.

POLICY MANUAL REVISIONS

There are no policy manual revisions associated with this SR.

IMPLEMENTATION

•       Any copies of the previous version of BFA Form 773 should be used up, then the new version can be printed for use.

•      Any unofficial Profit & Loss or Self-Employment logs should be discontinued and only the new official forms should be used upon receipt of this SR.

•      Previous English versions of form 77d that have already been printed may be used up then the new version should be used. Previous Spanish versions should be recycled, as the District Office locations are incorrect; use the new Spanish version immediately. Any Nepali translated 77d should be recycled.

These forms are available electronically, for Department staff only, in the DFA Folder on the N: Drive. These forms will be available to be batched from New HEIGHTS and will also be available, in English and Spanish, on NH EASY in January 2023.

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.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for BFA policy releases. This SR, and revised Online Manuals, will be available for agency staff in the Online Manual Library, and for public access on the Internet at https://www.dhhs.nh.gov/sr_htm/sr.htm, effective 01/03/2023

BFA/DMS:sh