BFA Form 800 "Application for Assistance" - New Hampshire

What Is BFA Form 800?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of BFA Form 800 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance.

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Download BFA Form 800 "Application for Assistance" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 800
Bureau of Family Assistance (BFA)
w ww.dhhs.nh.gov/dfa/index.htm
10/20
Welcome to the Department of Health & Human Services (DHHS),
Bureau of Family Assistance (BFA)
To apply for the programs and services we offer, you must fill out this Application for Assistance, then have an
interview, and give us proof of your household circumstances. Please read all of the information given to you, and
answer all of the questions as best as you can. Do not answer anything that you do not understand. If you need
help in filling out this Application, tell us. You have the right to immediately file your Application as long as it
contains the applicant’s name and address and the signature of a responsible household member or the
household’s authorized representative. However, we will be able to more quickly figure out if you can get benefits
if you complete the entire Application. If you only want Supplemental Nutrition Assistance Program (SNAP formerly
Food Stamp) benefits and are completing the full Application, please complete every Section except Section I.
BFA assistance is based on your income. Some BFA programs may also look at the cash value of things that you
own, your “assets,” when figuring out if you qualify for a program we offer.
the Social Security Administration (SSA). Members of
SNAP Benefits
your household who do not want to apply for benefits
do not need to provide a SSN. Giving us a SSN is
The
Supplemental
Nutrition Assistance Program
optional for persons who are not applying for
(SNAP) helps low-income people buy the food they
assistance. Giving us a SSN can save you time and
need for good health. You will need to have an
money getting needed verifications.
interview with a DHHS worker to see if you are eligible
for this program. Your SNAP benefits are based on the
If you are applying only for some members of your
date of application, which is the date your completed
family, such as a parent applying for Medical
application is received by the District Office. If you are
Assistance just for a child, you only have to give us the
child’s SSN or apply for a SSN for your child. Your
a resident of an institution who is jointly applying for
child’s eligibility for medical coverage will not be
SSI and SNAP benefits prior to leaving the institution,
affected if you only give us your child’s SSN.
the filing date of your application is your date of release
from the institution. With identification, you may get
If a SSN is not provided for each person who is
emergency SNAP benefits within 7 calendar days if:
applying for the listed programs, your application may
be denied or you may get less benefits. If someone
you have less than $150 in monthly gross income
wants help getting a SSN, call 1-800-772-1213 or visit
and no more than $100 in liquid resources;
socialsecurity.gov. TTY: 1-800-325-0778.
you have shelter costs that are higher than your
gross income and liquid resources; or
Applicants who only want Child Care do not have to
you are a migrant or seasonal farm worker who is
provide a SSN, but if SSNs are provided, it may help
destitute as defined in 7 CFR 273.10(e)(3).
shorten the eligibility verification process.
We ask for SSNs so we can verify identity, other
Social Security Numbers (SSN)
benefits received, earned and unearned income, and
resource information you give us. It will be shared and
The Federal Privacy Act of 1974 as amended, requires
verified with:
that we tell you the laws that allow us to ask for the
federal, state, and local entities;
SSN of each person requesting assistance, whether
offices within DHHS as allowed by federal law;
you are required to give them to us, and what we will
employment and unemployment databases;
do with them. SSNs are required for the following
the Internal Revenue Service and SSA;
programs. After each program is the law or regulation
contracted third parties;
that requires us to ask for these SSNs:
financial entities; and
FANF: 42 USC 405(c)(2), 45 CFR 205.52, RSA
other computer matching programs.
167:4-c, & RSA 167:79,iii(h).
The information will be used:
SNAP: RSA 167:4-c, Food and Nutrition Act of
to figure out if you are eligible or continue to be
2008 (formerly Food Stamp Act), as amended, 7
eligible for the assistance you requested;
USC 2011-2036, 7 CFR 273.2(b)(4)(i), & 7 CFR
to figure out the amount of your benefits or errors
273.6.
in your eligibility or benefits; and
Medical Assistance and other financial assistance:
in an investigation of suspected abuse of program
RSA 167:4-c, Section 2651 of PL 98-369, 42 CFR
law or rules.
435.910, 42 CFR 435.920, & 42 USC 1320b-7.
It may be disclosed to Federal and State agencies for
Each person who wants assistance from the above
official examination, and to law enforcement officials
programs must provide a SSN or apply for a SSN at
BFA SR 19-29
VISIT
WWW.NHEASY.NH.GOV
TO APPLY ONLINE!
(NA)
NH Department of Health and Human Services (DHHS)
BFA Form 800
Bureau of Family Assistance (BFA)
w ww.dhhs.nh.gov/dfa/index.htm
10/20
Welcome to the Department of Health & Human Services (DHHS),
Bureau of Family Assistance (BFA)
To apply for the programs and services we offer, you must fill out this Application for Assistance, then have an
interview, and give us proof of your household circumstances. Please read all of the information given to you, and
answer all of the questions as best as you can. Do not answer anything that you do not understand. If you need
help in filling out this Application, tell us. You have the right to immediately file your Application as long as it
contains the applicant’s name and address and the signature of a responsible household member or the
household’s authorized representative. However, we will be able to more quickly figure out if you can get benefits
if you complete the entire Application. If you only want Supplemental Nutrition Assistance Program (SNAP formerly
Food Stamp) benefits and are completing the full Application, please complete every Section except Section I.
BFA assistance is based on your income. Some BFA programs may also look at the cash value of things that you
own, your “assets,” when figuring out if you qualify for a program we offer.
the Social Security Administration (SSA). Members of
SNAP Benefits
your household who do not want to apply for benefits
do not need to provide a SSN. Giving us a SSN is
The
Supplemental
Nutrition Assistance Program
optional for persons who are not applying for
(SNAP) helps low-income people buy the food they
assistance. Giving us a SSN can save you time and
need for good health. You will need to have an
money getting needed verifications.
interview with a DHHS worker to see if you are eligible
for this program. Your SNAP benefits are based on the
If you are applying only for some members of your
date of application, which is the date your completed
family, such as a parent applying for Medical
application is received by the District Office. If you are
Assistance just for a child, you only have to give us the
child’s SSN or apply for a SSN for your child. Your
a resident of an institution who is jointly applying for
child’s eligibility for medical coverage will not be
SSI and SNAP benefits prior to leaving the institution,
affected if you only give us your child’s SSN.
the filing date of your application is your date of release
from the institution. With identification, you may get
If a SSN is not provided for each person who is
emergency SNAP benefits within 7 calendar days if:
applying for the listed programs, your application may
be denied or you may get less benefits. If someone
you have less than $150 in monthly gross income
wants help getting a SSN, call 1-800-772-1213 or visit
and no more than $100 in liquid resources;
socialsecurity.gov. TTY: 1-800-325-0778.
you have shelter costs that are higher than your
gross income and liquid resources; or
Applicants who only want Child Care do not have to
you are a migrant or seasonal farm worker who is
provide a SSN, but if SSNs are provided, it may help
destitute as defined in 7 CFR 273.10(e)(3).
shorten the eligibility verification process.
We ask for SSNs so we can verify identity, other
Social Security Numbers (SSN)
benefits received, earned and unearned income, and
resource information you give us. It will be shared and
The Federal Privacy Act of 1974 as amended, requires
verified with:
that we tell you the laws that allow us to ask for the
federal, state, and local entities;
SSN of each person requesting assistance, whether
offices within DHHS as allowed by federal law;
you are required to give them to us, and what we will
employment and unemployment databases;
do with them. SSNs are required for the following
the Internal Revenue Service and SSA;
programs. After each program is the law or regulation
contracted third parties;
that requires us to ask for these SSNs:
financial entities; and
FANF: 42 USC 405(c)(2), 45 CFR 205.52, RSA
other computer matching programs.
167:4-c, & RSA 167:79,iii(h).
The information will be used:
SNAP: RSA 167:4-c, Food and Nutrition Act of
to figure out if you are eligible or continue to be
2008 (formerly Food Stamp Act), as amended, 7
eligible for the assistance you requested;
USC 2011-2036, 7 CFR 273.2(b)(4)(i), & 7 CFR
to figure out the amount of your benefits or errors
273.6.
in your eligibility or benefits; and
Medical Assistance and other financial assistance:
in an investigation of suspected abuse of program
RSA 167:4-c, Section 2651 of PL 98-369, 42 CFR
law or rules.
435.910, 42 CFR 435.920, & 42 USC 1320b-7.
It may be disclosed to Federal and State agencies for
Each person who wants assistance from the above
official examination, and to law enforcement officials
programs must provide a SSN or apply for a SSN at
BFA SR 19-29
VISIT
WWW.NHEASY.NH.GOV
TO APPLY ONLINE!
(NA)
for the purpose of apprehending persons fleeing to
You are required to pay back any benefits or services
avoid the law. If a SNAP claim arises against your
received in error, regardless of whether you made a
household,
the
information
on
this application,
mistake in the information you provided, or failed to
including all SSNs, may be referred to Federal and
provide, to us. If you get SNAP, you must also pay back
State agencies, as well as private claims collection
any benefits you received in error if we made a mistake
agencies, for claims collection action.
in processing your case.
We do not give SSNs or any other information
Financial or Medical Child Support
regarding non-applicants to the US Citizenship and
Immigration Services (USCIS), or any other agency not
If you are applying for TANF cash payments, your
directly connected with programs and/or services
receipt of such assistance is an assignment to DHHS
offered by DHHS.
of your rights to financial child support. Without signing
any other form, you give DHHS the right to collect and
Emergency Medicaid for Non-Citizens
keep financial child support payments made on behalf
Emergency Medicaid may be available to certain non-
of your children who receive assistance. RSA 161-C:22
citizens, regardless of their immigration status, to cover
DHHS collects and keeps the support to partially offset
some emergency services,
including labor
and
the amount of cash assistance paid to you. If support
delivery. Social Security Numbers are not needed to
payments are equal to or more than the amount we
apply for Emergency Medicaid.
give you, your cash assistance case will be closed and
the support payments sent to you.
Citizenship & Identity
Receipt of Children’s Medicaid is an assignment of
You must declare and prove the citizenship or non-
medical child support rights. This means that you must
citizenship status of each household member applying
cooperate with DHHS to establish and enforce medical
for assistance. Non-citizens applying for assistance,
child support for your children. Medical child support
except Emergency Medicaid, must provide USCIS
usually means health insurance provided by the absent
documentation
of qualified
alien
status. USCIS
parent, but can also be an ongoing dollar amount paid
documentation will be verified and non-citizen status of
by the other parent to allow you to buy health insurance
applicant household members will be subject to
for your children.
verification through the submission of information from
If you receive money to purchase medical insurance,
the
application
to
USCIS,
and
the
submitted
this money will be kept by the State if you receive
information received from USCIS may affect eligibility
Medicaid for your child and will be used to pay back the
and benefits.
state and federal governments. If paternity is not
established for any of your children who are getting
Third Party Insurance or Medical Payments
Medicaid, you must also cooperate with DHHS to
If you are applying for Medical Assistance, receipt of
legally establish paternity.
such assistance is an assignment to DHHS of your
The assignment of support rights is a requirement .
rights to all third party insurance or medical payments
Your rights and responsibilities and the penalty for
without anyone having to sign any other form. All
refusal without a good reason, will be explained to you
available parties must be billed and all resulting
when you meet with your District Office worker.
payments must be applied to the cost of medical care
Begin Date for Medicaid Eligibility
before DHHS will pay. Also, if you receive a settlement
or an award from a liable third party, you must pay
Your Medicaid eligibility generally begins on the day
DHHS back for related medical services we paid. RSA
that you meet all the requirements for the program you
167:14-a
applied for, including the resource limit.
Benefits Received in Error
AGENCY USE ONLY
This is your record of application and will be filled out by a Department of Health and Human Services worker and returned to you. BFA has
received
a completed application for
from
on
District Office
Signature of Worker
NH Department of Health and Human Services (DHHS)
BFA Form 800
Bureau of Family Assistance (BFA)
w ww.dhhs.nh.gov/dfa/index.htm
10/20
A. Please tell us about who you are and where you live.
Full Legal Name:
Primary Language:
Current Place of Residence:
Own home
Nursing Facility
Adult Family Home
Assisted Living
Congregate Housing
Homeless
Hospital
Hotel/Motel
Residential Care Facility
Other
Street Address:
Mailing Address:
(if different)
City/State/Zip:
Home Phone:
Work Phone:
Cell/Message:
E-Mail Address:
I do not have an E-Mail address
Does anyone in your family have Medicare Part A or B?
Y
N
Why do you need our help?
Information Supplier:
(if different from applicant)
Name
Address
Phone #
B. Please tell us about the people you live with.
Start with yourself and list ALL of the people living with
you.
You do not have to give the Social Security Number or citizenship status of any individual who is not applying for
assistance.
Student
RID
(Yes or No.
(BFA Use
Full Legal Name
SSN
DOB
Relation to you
U.S. Citizen?
If Yes, put grade too)
Only)
Y
N
SELF
1.
Y
N
2.
Y
N
3.
4.
Y
N
Y
N
5.
6.
Y
N
C. I want to apply for:
(TYPES OF ASSISTANCE REQUESTED)
ALL PROGRAMS
Cash
SNAP
Child Care
Medicare Savings Programs (MSP) [QMB/QWDI/SLMB/SLMB135]
Home and Community-Based Care (HCBC)
Nursing Facility (NF) Services - Facility Name:
Medical Assistance –
if you need Medical Assistance for a child, pregnant w omen, or parent/caretaker relative of a child, you must also
complete the insert entitled Medical Assistance for Children, Pregnant Women, and Parent/Caretaker Relative s Insert
D.
The following information is collected to be sure that everyone is served fairly without regard to race, color, or
national origin. Your answers are voluntary. The information provided will not affect your eligibility or benefit
amount. For ethnicity, please select one response. For race, please select all that apply.
Ethnicity:
Are you Hispanic or Latino?
Yes
No
Native Hawaiian or Other Pacific
Race:
Are you: White?
Y
N
Asian?
Y
N
Islander?
Y
N
Black or African American?
Y
N
American Indian or Alaskan Native?
Y
N
AGENCY USE ONLY:
Forms Given:
725
177
RFA#
Case #
Cash
OPEN
CLOSE
DENY
DATE:
DO:
SNAP
OPEN
CLOSE
DENY
DATE:
DO:
MA
OPEN
CLOSE
DENY
DATE:
DO:
CM/MCPW
OPEN
CLOSE
DENY
DATE:
DO:
Child Care
OPEN
CLOSE
DENY
DATE:
DO:
EBT Card Status:
None
Active
Bad Address
Deactivated/Cancelled
Undelivered
SR 20-02
(N/A)
E. Please tell us about all income for everyone in your home.
G. Your Expenses:
Your Wages:
$
Rent
:
$
Weekly
Bi-Weekly
Monthly
(monthly)
Other Wages:
$
Mortgage
:
$
Weekly
Bi-Weekly
Monthly
(monthly)
Other Wages
$
$
Weekly
Bi-Weekly
Monthly
Lot Rent/Condo Fee
:
(monthly)
Has anyone recently lost a job?
Yes
No
Taxes
:
$
(yearly)
If yes, who?
When?
/
/
Dependent Care:
$
SSA/SSDI: $
Spousal Support: $
Medical Expenses:
$
SSI: $
Unemployment: $
Cost of doing business:
$
Have you gotten m ore than $20 in fuel assistance
VA: $
Child Support: $
Yes
No
in this or the past 12 m onths?
Pension: $
Other: $
Do you pay for the following utilities
F. Please tell us about all assets for everyone in your home.
separate from your rent or mortgage?
Heat:
Yes
No
$
$
Checking/Savings:
Other Chk/Save:
Stocks/Bonds/CD’s:
$
$
Phone:
Yes
No
IRA:
Your or Your
Electric:
Yes
No
Spouse’s Annuity:
$
$
Other Assets:
$
: $
Other:
Yes
No
Trusts:
Life Insurance
Internet(including mobile)
Yes
No
Vehicle (Yr/Mdl):
Vehicle (Yr/Mdl):
H. Please answer all questions.
1. Are you a migrant or seasonal farm worker?
Yes
No
2. Have you or anyone in your household received SNAP assistance for this month?
Yes
No
3. Are you currently living in a shelter for battered individuals?
Yes
No
4. Is anyone in your household blind or disabled?
Yes
No
5. Have you sold or transferred property in the last 5 years?
Yes
No
6. Is anyone in your household currently receiving assistance from another State?
Yes
No
If yes, which State?
What kind of assistance?
I.
Do you only want SNAP? If so, you can skip to Section J now. If you want cash, medical or child care
help, please answer all questions in this Section before proceeding to Section J.
1. Is anyone in your household pregnant or has anyone given birth in the last 3 months?
Yes
No
2. Do you have any unpaid medical bills from the past 3 months that you would like help paying?
Yes
No
3. If you are applying for Financial Assistance to Needy Families (FANF), is the father’s name blank or
Yes
No
“not stated” on the birth certificate for any of your children?
4. If applying for FANF, how many absent parents?
5. Do you or any other household member have health insurance other than Medicaid?
Yes
No
If yes, name of Insurer?
Policy Number:
J. Signatures
I C
, U
P
O
P
, T
I H
R
T
I
O
T
A
, I
A
ERTIFY
NDER
ENALTY
F
ERJURY
HAT
AVE
EVIEWED
HIS
NFORMATION
N
HIS
PPLICATION
NCLUDING
NY
I
I
O
T
I
; I
I
T
A
C
T
T
B
O
M
K
, I
T
NFORMATION
NDICATED
N
HE
NSERT
T
S
RUE
ND
OMPLETE
O
HE
EST
F
Y
NOWLEDGE
NCLUDING
HE
I
C
C
A
A
S
. I U
A F
NFORMATION
ONCERNING
ITIZENSHIP
ND
LIEN
TATUS OF THE MEMBERS APPLYING FOR ASSISTANCE
NDERSTAND
ULL
F
A
M
E
I
M
N
B
C
B
M
E
C
B
D
.
INANCIAL
ND
EDICAL
LIGIBILITY
NTERVIEW
AY
EED TO
E
ONDUCTED
EFORE
Y
LIGIBILITY
AN
E
ETERMINED
Applicant Signature
Date
Signature of Person Helping the Applicant
Date
Relationship to Applicant
I w ithdraw m y application for:
Cash
Medical Assistance
SNAP
Child Care
HCBC/NF
MSP
Signature
Date
I certify that I have given the above individual(s) the opportunity to review this application. I also certify that I have pr ovided a copy
of this form , if one w as requested.
Printed Name & Signature
Title/Agency
Date
NH Department of Health and Human Services (DHHS)
BFA Form 811R
Bureau of Family Assistance (BFA)
w ww.dhhs.nh.gov/dfa/index.htm
01/19
APPLICATION: YOUR RIGHTS AND RESPONSIBILITIES
Time Limits
You can only receive Financial Assistance to Needy Families for 60-months in your lifetime. Months you received
this assistance while you were a child do not count towards the lifetime limit. Your time limit begins when you
receive benefits as an adult. There is no time limit on State Supplement Programs, Medical Assistance,
SNAP benefits, or child care assistance.
amount of income of any member in your
Administrative Appeal
household;
You or someone representing you may request an
all household changes, such as marriage, divorce,
Administrative Appeal if you are not satisfied with
new baby, child leaves, etc.;
any decision regarding eligibility made by DHHS.
child care provider;
You may be represented by an attorney, yourself, or
resources (e.g., cash, stocks, bonds, or money in
another person, such as a relative or friend, at an
a bank or savings account);
Administrative Appeal. DHHS will not pay for the
receipt of any lump sum payment or settlement;
cost of any legal services, but there are free and
residence, or shelter costs; or
reduced cost legal services available in NH. An
dependent care costs, child support payments or
Administrative Appeal may be requested either
medical deductions, or other changes that may
affect the amount of your household’s benefits.
verbally or in writing by contacting a District Office or
DHHS, 105 Pleasant Street, Concord, NH 03301-
Protection of Medical Assistance for
6521. Telephone (603) 271-4292 or 1-800-852-3345
Social Security Beneficiaries
ext 4292; TDD Access: Relay NH 1-800-735-2964
If you are receiving cash assistance under the OAA,
or 711.
ANB, or APTD program, and a Social Security cost-
Quality Control
of-living increase or this increase combined with an
increase in other income makes you ineligible for
Your case may be selected for a quality control or
financial assistance, you may still be entitled to
other governmental review. Such a review entails an
in-depth investigation into your household’s financial
Medical Assistance under the Pickle Amendment
policy.
or medical situation, living arrangements and other
circumstances. We may be contacting banks,
Once you begin receiving Medical Assistance under
employers, companies, merchants, child care
the Pickle Amendment, future Social Security cost-
providers,
and
other
appropriate
sources,
of-living increases will not affect your eligibility.
concerning your household and statements you
However, other changes in your circumstances can
made to DHHS. Failure to cooperate in these
still make you ineligible for Medical Assistance.
reviews could result in the loss of your benefits.
If you are eligible to receive money payments under
one of the above programs, but choose not to
Reporting Changes
receive a payment, you will NOT be entitled to this
You will be required to periodically complete a
protection of your Medical Assistance under the
review of your circumstances. Your cash, child care,
Pickle Amendment.
and SNAP case could be closed, and/or your
Notice to Immigrant Families
eligibility for Medical Assistance may be affected, if
you do not completely fill out the form and return it
If you get help with health care or SNAP, it will not
by the due date and participate in a personal
affect your immigration status. If you or members of
interview, if required.
your family used or received Medicaid or SNAP, it
will not affect your or your family members’ ability to
If you only get SNAP benefits and you have a 4, 5,
become U.S. citizens.
or 6-month eligibility period, you only need to report
those changes in household circumstances that
However, if you get cash assistance such as TANF
would place your household’s income above 130%
or help with the cost of nursing home care, it might
of the poverty level.
create problems with becoming a U.S. citizen,
especially if the benefits are your family’s only
If you receive cash, child care, Medical Assistance,
or if your SNAP eligibility period is not 4, 5, or 6
income. Before you apply, you may want to talk with
months, then you must notify the Department within
an agency that helps immigrants with legal
questions or contact the US Citizenship and
10 calendar days after the change happens for
changes in factors that affect eligibility, such as:
Immigration Services (USCIS).
BFA SR 19-29
source of income;
(NA)
hours worked by a household member;
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