BFA Form 65 "Client Statement" - New Hampshire

What Is BFA Form 65?

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, 2019;
  • 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;
  • 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 65 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 65 "Client Statement" - New Hampshire

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NH Department of Health & Human Services (DHHS)
BFA Form 65
Bureau of Family Assistance (BFA)
10/19
Client’s Printed Name
Date
Client’s Case Number
CLIENT STATEMENT
Shelter Statement
Fraud Statement
Voluntarily Withdrawing
Application
Voluntarily Terminating
Initiate, Change, or Remove a
Change the Amount of a
Assistance
Vendor Payee
Vendor Payment
Lack of Adequate Child Care
Loss of Employment
Other:
Client’s Statement:
Signature
Date
Printed Name
This institution is an equal opportunity provider.
Return to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
BFA SR 19-29
(3YC)
NH Department of Health & Human Services (DHHS)
BFA Form 65
Bureau of Family Assistance (BFA)
10/19
Client’s Printed Name
Date
Client’s Case Number
CLIENT STATEMENT
Shelter Statement
Fraud Statement
Voluntarily Withdrawing
Application
Voluntarily Terminating
Initiate, Change, or Remove a
Change the Amount of a
Assistance
Vendor Payee
Vendor Payment
Lack of Adequate Child Care
Loss of Employment
Other:
Client’s Statement:
Signature
Date
Printed Name
This institution is an equal opportunity provider.
Return to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
BFA SR 19-29
(3YC)