DFA Form 474 "Attestation and Verification of Food Stamp (Fs) Household Disaster" - New Hampshire

What Is DFA Form 474?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Division 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 April 1, 2017;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Division of Family Assistance;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of DFA Form 474 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Division of Family Assistance.

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Download DFA Form 474 "Attestation and Verification of Food Stamp (Fs) Household Disaster" - New Hampshire

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NH Department of Health and Human Services (DHHS)
DFA Form 474
Division of Family Assistance (DFA)
04/17
ATTESTATION AND VERIFICATION OF FOOD STAMP (FS) HOUSEHOLD DISASTER
To get replacement FS benefits for food destroyed in a disaster you must tell us about the disaster within 10 days
of it happening
After you tell us about the disaster
use this form to attest to and prove the disaster (fire
flood
.
,
,
,
power outage
etc
) in which you lost food bought with FS benefits
You must complete both parts of this form
You
,
.
.
.
must then return it to us within 10 days of telling us about the disaster
The dollar amount that is replaced
.
will not be more than your monthly benefit allotment
.
You must tell us the date of the disaster and the value of food lost
You must also give us proof of the disaster
.
.
Failure to do so could result in a denial or delay of you getting your replacement FS benefits
.
P
A
R
FS B
R
ART
EPLACEMENT
ENEFITS
EQUEST
:
Name of FS Household Member
Case Number
Street Address
Phone #
City/Town
State
Zip
that I lost food bought with my household’s
I attest under penalty of unsworn falsification
pursuant to RSA 641
3
,
:
,
FS benefits
due to ________________ (example
fire
flood
power outage
etc
)
I have read and understand the
,
:
,
,
,
.
.
penalties for giving false information explained on the back of this form
.
$
Date of Disaster
Value of food lost that was bought with your FS benefits
(If this number is higher than the amount of FS you got in the month of the disaster, you will
only get the amount you got that month.)
Signature of FS Household Member
Date
P
B
P
D
(
)
ART
ROOF OF
ISASTER
FIRE
FLOOD
POWER OUTAGE
ETC
:
,
,
,
.
You must give us proof that your household had a disaster
Do you have a letter from an agency
such as an
.
,
insurance company
fire department
power company
or Red Cross? If so
you do not have to complete this part
,
,
,
,
.
That letter from the agency is proof of your disaster
If you include that letter when you return this form
you only
.
,
need to complete Part A above
If you do not have a letter from an agency about your disaster
you must either
.
,
:
Have someone other than yourself fill out the box below
This person could be your landlord
neighbor
or any
.
,
,
other person who is not a member of your FS household and knows about the disaster
.
that the above named person’s statement is
I attest under penalty of unsworn falsification
pursuant to RSA 641
3
,
:
,
true and accurate to the best of my knowledge
.
Printed name
________________________________________ Phone number
_____________________
:
:
Relationship to household
__________________________________________________________________
:
Signature
_____________________________________________________________ Date
____________
:
:
OR
If you cannot reach anyone who can fill out the above box
we can try to reach someone for you
Tell us the
,
.
person’s name
contact information
and relationship to you
This person may work for an agency
such as an
,
,
.
,
insurance company
fire department
power company
or Red Cross
This person could also be your landlord
,
,
,
.
,
neighbor
or any other person who is not a member of your FS household and has knowledge of the disaster
,
.
Name
___________________________________________________ Phone #
______________________
:
:
Relationship to you
_______________________________________________________________________
:
Return this form to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
DFA SR 17-10
CentralizedScanUnit@dhhs.state.nh.us
(A)
NH Department of Health and Human Services (DHHS)
DFA Form 474
Division of Family Assistance (DFA)
04/17
ATTESTATION AND VERIFICATION OF FOOD STAMP (FS) HOUSEHOLD DISASTER
To get replacement FS benefits for food destroyed in a disaster you must tell us about the disaster within 10 days
of it happening
After you tell us about the disaster
use this form to attest to and prove the disaster (fire
flood
.
,
,
,
power outage
etc
) in which you lost food bought with FS benefits
You must complete both parts of this form
You
,
.
.
.
must then return it to us within 10 days of telling us about the disaster
The dollar amount that is replaced
.
will not be more than your monthly benefit allotment
.
You must tell us the date of the disaster and the value of food lost
You must also give us proof of the disaster
.
.
Failure to do so could result in a denial or delay of you getting your replacement FS benefits
.
P
A
R
FS B
R
ART
EPLACEMENT
ENEFITS
EQUEST
:
Name of FS Household Member
Case Number
Street Address
Phone #
City/Town
State
Zip
that I lost food bought with my household’s
I attest under penalty of unsworn falsification
pursuant to RSA 641
3
,
:
,
FS benefits
due to ________________ (example
fire
flood
power outage
etc
)
I have read and understand the
,
:
,
,
,
.
.
penalties for giving false information explained on the back of this form
.
$
Date of Disaster
Value of food lost that was bought with your FS benefits
(If this number is higher than the amount of FS you got in the month of the disaster, you will
only get the amount you got that month.)
Signature of FS Household Member
Date
P
B
P
D
(
)
ART
ROOF OF
ISASTER
FIRE
FLOOD
POWER OUTAGE
ETC
:
,
,
,
.
You must give us proof that your household had a disaster
Do you have a letter from an agency
such as an
.
,
insurance company
fire department
power company
or Red Cross? If so
you do not have to complete this part
,
,
,
,
.
That letter from the agency is proof of your disaster
If you include that letter when you return this form
you only
.
,
need to complete Part A above
If you do not have a letter from an agency about your disaster
you must either
.
,
:
Have someone other than yourself fill out the box below
This person could be your landlord
neighbor
or any
.
,
,
other person who is not a member of your FS household and knows about the disaster
.
that the above named person’s statement is
I attest under penalty of unsworn falsification
pursuant to RSA 641
3
,
:
,
true and accurate to the best of my knowledge
.
Printed name
________________________________________ Phone number
_____________________
:
:
Relationship to household
__________________________________________________________________
:
Signature
_____________________________________________________________ Date
____________
:
:
OR
If you cannot reach anyone who can fill out the above box
we can try to reach someone for you
Tell us the
,
.
person’s name
contact information
and relationship to you
This person may work for an agency
such as an
,
,
.
,
insurance company
fire department
power company
or Red Cross
This person could also be your landlord
,
,
,
.
,
neighbor
or any other person who is not a member of your FS household and has knowledge of the disaster
,
.
Name
___________________________________________________ Phone #
______________________
:
:
Relationship to you
_______________________________________________________________________
:
Return this form to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
DFA SR 17-10
CentralizedScanUnit@dhhs.state.nh.us
(A)
PENALTY WARNING
Anyone who intentionally makes a false statement or misrepresents his or her circumstances may be
found guilty of violating state law. The penalties are: a class A felony where the value of the monetary
award or goods or services exceeds $1,000; a class B felony where the value exceeds $100; and a
misdemeanor where the value does not exceed $100. RSA 167:17-b and 17-c.
Anyone who commits an intentional program violation (IPV) in the Food Stamp Program will not get
these benefits for 12 months for the 1st IPV, 24 months for the 2nd IPV, and permanently for the 3rd
IPV. 7 CFR 253.8(b).
NOTICE OF RIGHT TO AN ADMINISTRATIVE APPEAL
You or someone representing you may request an Administrative Appeal if you are not satisfied with
DHHS’ decision to deny or delay the replacement of your lost benefits. Replacements will not be
made while your appeal is pending. To request an Administrative Appeal, you can contact the
Appeals Unit directly at 1-800-852-3345, extension 4292. You can also write your own letter to ask for
an appeal. Send your written request to DHHS at 105 Pleasant Street, Concord, NH 03301-6521.
You may represent yourself, have an attorney, or another person such as a relative or a friend to
represent you at an Administrative Appeal. DHHS will not pay for the cost of any legal services you
may want. However, there are free and reduced cost legal services available in NH. For information
on these services or a referral, please call New Hampshire Legal Aid at 1-800-639-5290.
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