SR 97-04 Dated 02/97

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases Application Form 800 which has been revised to reflect state and federal welfare reform initiatives. The new Form 800 also contains federally mandated notification to applicants concerning new policies on time limits for Title IV-A funded assistance and ineligibility of fugitive felons and probation or parole violators for financial assistance or food stamps benefits. Form 800(i) is not being revised at this time since the changes made to Form 800 are not referenced in the Instructions.

POLICY

Most of the changes were editorial or technical. References to JOBS and AFDC throughout the Form were removed and replaced where appropriate by Temporary Assistance to Needy Families (TANF), New Hampshire Employment Program (NHEP) or Family Assistance Program (FAP). "Department of Health and Human Services" has replaced "Division of Human Services" throughout to reflect organizational changes in the Department. "Child Care Assistance" has replaced all references to "Social Services" or "Child Day Care".

The following substantive changes have been made to Form 800:

 The Form’s introduction, beginning "Dear Applicant", includes an additional paragraph to explain assignment of medical support rights in Medicaid cases. In order to accommodate this requirement in the available space, it was necessary to drop the brief description of Employment Support Services.

 On page 1, in the section PROGRAM(S) FOR WHICH YOU ARE APPLYING, check boxes were included for Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB).

 "Homeless (no nighttime residence)" has been included under LIVING ARRANGEMENTS on page 2, Section 2. Previously the form did not contain a way to indicate this situation.

 Also on page 2, "Fuel Assistance" is specifically noted where the applicant is asked if anyone else pays a portion of their utilities. This has been a source of QC errors and was added as a reminder to ask if such aid was being received.

 On page 6, in the block captioned IMPORTANT INFORMATION - PLEASE READ BEFORE SIGNING, the applicant is informed that if they are a fleeing felon, probation or parole violator, they will be permanently ineligible for food stamps and financial assistance. This meets federal notification requirements of the new restrictions imposed on recipients and allows the individual signing the form to execute a sworn statement on behalf of the entire household. The signature line for someone other than the applicant completing the application now also asks for that person’s relationship to the applicant.

 On the tear-off sheet entitled YOUR RIGHTS AND RESPONSIBILITIES NOTICE, there is a new entry advising clients that benefits received through IV-A funding may be limited to no more than 60 months. This addition reflects federal and state welfare reform initiatives. The WARNING on the reverse side of this NOTICE has been revised slightly to include new penalties for deliberate violations of NHEP, FAP, or Food Stamp rules. Also, on the reverse side of this NOTICE, individuals are notified of penalties related to convictions for using food stamps to buy or sell illegal drugs, certain prescription drugs, firearms, ammunition or explosives, or for trafficking in food stamps of $500 or more.

PROCEDURES

Because case technicians are able to cover assignment of rights to medical support when explaining the application form to potential clients, it is no longer required to include the Office of Child Support’s "SUPPLEMENTAL INFORMATION FOR MEDICAID APPLICANTS AND RECIPIENTS" form (no number) in the initial interview.

IMPLEMENTATION

Supplies of the current Form 800 should be exhausted before the revised Form 800 is used. Revised Form 800 (SR 97-4, 2/97) may be obtained from Logistics on or after 2/1/97

CLIENT NOTIFICATION

Clients have been notified of policy changes incorporated in this form through client mailings which explained welfare reform initiatives. No additional notification is necessary.

TRAINING

No training is planned due to the procedural nature of this SR.

POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed after its contents have been noted and its posting instructions carried out.

DISTRIBUTION

This SR only will be distributed according to the narrative distribution list for the FAM, AAM and Forms. This SR and pages will be distributed to all holders of the FAM, AAM and Forms Manuals.

OES/mgd:s