SR 97-36 Dated 10/97

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases Forms NHEP255, Employment Support Services Payment Request Invoice, and NHEP257, Tuition Payment Request Invoice, and their Instructions. As these Forms are used exclusively by the New Hampshire Employment Program (NHEP) to provide employment support services to participants in NHEP work-related activities, it was decided to number these forms using the NHEP prefix so that they could be printed and distributed directly by New Hampshire Employment Security (NHES). See SR 97-33 for a detailed description of this process.

This SR also obsoletes the previous non-NHEP versions of the above forms, and releases revised Forms AW9, Alternate W9 Form CIS, AW-9L, Request for W9 Information, and 251, Provider Enrollment and Registration Form. These forms are used to gather information necessary to enroll providers of child care assistance and employment and training support services in order that they may be paid by the Department of Health and Human Services (DHHS) for services rendered to clients.

The changes made to Forms 255 and 257 to create the new NHEP versions are substantial and are detailed in the "Forms Revision" section below. Changes to Forms 251, AW9, and AW-9L are also detailed below.

In addition, the following new Service Codes associated with Employment and Training Support Services not yet available to NHEP participants have nonetheless been included on the revised Forms 251 and NHEP255:

Although the services associated with these codes have not yet been released (it is planned that policy establishing these support services will be released in November 1997), it was decided to include them on the revised forms in anticipation of their use and to avoid the necessity of making additional forms revisions in the near future.

Note: Do not use these codes at this time. Until policy is released establishing the support services associated with these codes, Forms 255 or 257 submitted with any of the above codes circled will be rejected by the Bureau of Data Management (BDM).

Similarly, a checkbox has been added to Forms NHEP255 and NHEP257 to allow the NHEP Employment Support Counselor to indicate if the individual named on the form is receiving services as part of expanded Extended Case Management services. These expanded services are not yet available.

Note: Do not use this box until further notice. As with the services above, it is anticipated that revised Extended Case Management policy will be released in November, 1997.

FORMS REVISIONS

Forms AW9, Alternate W9 Form-CIS and AW-9L, Request for W9 Information

Forms AW9, Alternate W9 Form-CIS and AW-9L, Request for W9 Information, are used to gather Taxpayer Identification Numbers from providers of services in order that DHHS may share payment information with the Internal Revenue Service. Form AW9 is completed by the provider; Form AW-9L is a cover letter accompanying Form AW9.

Minor text and formatting revisions have been made to the instructional information on the Forms regarding where completed Forms AW9 are to be sent. Previously, all Forms AW9 were to be returned to the District Office along with Form 251, Provider Enrollment and Registration Form; under new policy, child care providers return these Forms directly to BDM,

while providers of Employment and Training Support Services (ETSS) are directed to return the Forms to the NHEP team.

Form 251, Provider Enrollment and Registration Form

Form 251, Provider Enrollment and Registration Form, is a three part NCR document used to enroll and register Child Care Providers, and to enroll ETSS providers so they can receive direct payments from DHHS. Included in this definition are providers of non-contract child care, books, supplies, fees, job tools, uniforms, tuition, automobile repairs, and other authorized support services for participants in the NHEP.

The front of Form 251 has been revised in the following manner:

 The "District Office Use Only" box at the top has been removed and replaced with three "Transaction Codes."

 Text indicating that Social Security Number is "Optional if registration only" (child care assistance) has been deleted.

 A new Section has been added to list "Services Provided" and the "Effective Date" of services.

 The "State Office Use Only" box at the bottom of the Form has been expanded to include checkboxes for "Payee," (Client or Provider), and Y/N for BDM to indicate whether Form AW-9, Alternate W9 Form CIS is attached, and whether the provider named must receive IRS Form 1099 at the end of the current year. This section is only used by BDM.

The back of the Form, which contains information on the enrollment process and instructions for completion of the Form itself, has been revised accordingly.

Form 251(I), Instructions for Form 251, has also been substantially revised and simplified. The "Instructions" section now differentiates between procedures for processing Forms 251 from child care providers and from providers of Employment and Training Support Services and how the various copies of the Form are distributed, depending on the type of provider submitting the Form. The "Retention" section also discusses where and by whom the various copies of Form 251 are retained.

Form NHEP255, Employment and Training Support Services Payment Request Invoice

Form NHEP255 is a three part NCR document used as a billing form for the provider of ETS services and as an authorization for payment of the bill. It replaces Form 255, Fees, Supplies and Automobile Repairs Payment Request Invoice. To create Form NHEP255, the following revisions were made to Form 255:

 The words "Form NHEP255" have been added in bold capital letters directly above the Form title to make it easier for BDM to identify and correctly file these forms when they arrive at State Office.

 The statement at the top of Form 255 regarding post-secondary tuition costs has been removed.

 A new section has been added to list "Type of Service Provided."

 The "Authorization for Payment section at the bottom of the Form has been expanded to include 3 new NHEP activities: 09, "Single Course;" 10, "Barrier Resolution;" and 11, "Self-Initiated." Also, 03, "Job Skills Training," has been changed to "Vocational Skills Training;" and 08 ,"Other Approved Work Program," has been changed to "Alternative Work Experience Program."

 The "Distribution" instructions have been changed to reflect changes in the colors of the form copies. Form 255 comprised green, pink, and blue copies; Form NHEP255 is composed of white, canary, and pink copies.

The back of the Form, which contains detailed instructions for completion of the Form itself, has been revised accordingly.

Form NHEP257, Tuition Payment Request Invoice

Form NHEP257, Tuition Payment Request Invoice, is a three part NCR form used by providers of education and training programs to bill DHHS for tuition costs of NHEP recipients in approved education and training programs, and as by the NHEP Employment Support Counselor to authorize these payments. It differs from original Form 257 in the following ways:

 "District Office Address" at the top of the Form has been deleted and replaced with two large sections for "Provider Name and Address" and "New Hampshire Employment Program Address."

 "Provider’s Key Name" has been added to the "Request for Payment" section, and the section has been reformatted.

 The "Authorization for Payment" section has been revised to eliminate "On-the-Job Training" (Activity code 07) as an authorized activity for Tuition Payment. Under NHEP, there are no provisions for tuition assistance for OJT activities.

The back of Form NHEP257, containing instructions for completion of the Form, has been revised accordingly from Form 257.

IMPLEMENTATION

Forms AW9

Because the changes to this Form are minor and technical in nature, the current version of this Form may continue to be used until stocks are depleted.

Form AW-9L

The current version of Form AW-9L may be used until the revised version returns from printing. At that time, an initial supply will be sent to District Offices and to each NHEP team. When the version released by this SR is received, discontinue use of the previous version

dated 9/95 and destroy or recycle all existing copies.

Form 251

The current version of Form 251 may continue to be used until the revised version returns from printing. At that time, an initial supply will be sent to District Offices and to each NHEP team. When the version released by this SR is received, discontinue use of previous versions and destroy or recycle all copies of these Forms dated 11/96 or earlier.

Forms NHEP255 and NHEP257

BDM will continue to accept current Forms 255 and 257 until the NHEP versions are available through the NHES forms ordering process. At that time, an initial supply will be sent to each NHEP team. When the initial supplies of Forms NHEP255 and NHEP257 are received, immediately discontinue usage and destroy or recycle all previous versions of Forms 255 and 257 dated 11/96 or earlier.

Interim Procedures for Form 255

Until NHEP teams receive a supply of Form NHEP255, NHEP Employment Support Counselors using current Form 255, Fees, Supplies, and Automobile Repairs Payment Request Invoice, must write the appropriate 2 digit Service code for the service being authorized directly above the check box entitled "For Auto Repairs." For example, if authorizing payment for Books and Supplies, write "04" directly above the check box for auto repairs.

At this time, only the following Service codes are to be written on Form 255:

CLIENT NOTIFICATION

No client notification is necessary due to the procedural nature of this SR.

TRAINING

NHEP teams received training on the use of the new Forms as part of comprehensive training on the Work For Benefits (WFB) component of the NHEP. Policy implementing WFB was released in SR 97-38.

POSTING INSTRUCTIONS

PEN AND INK CHANGE TO THE FAM

On the first page of Part 808, please write the following: "Per SR 97-36, Forms 255 and 257 have been replaced by Forms NHEP255 and NHEP257."

DISPOSITION

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

DISTRIBUTION

This SR only is being distributed according to the narrative SR distribution list for the Family Assistance Manual (FAM). The SR and attachments are being distributed to all holders of FAM and Forms Manuals.

JG/DTA/RQY:s

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CERTIFICATE OF DESTRUCTION

I hereby certify that all copies of Forms 251and 255, SR 96-9/November 1996, Form 257, SR 93-27/October 1993, and Form AW-9L, SR 95-57/September 1995, have been destroyed.

Office Manager:    District Office/NHEP Site     

NOTE: Return this certificate to Stock Control at DHHS State Office, 6 Hazen Drive, Concord, NH 03301 after the instructions in the SR have been carried out.