BFA Form 768 "Shared Shelter Arrangements" - New Hampshire

What Is BFA Form 768?

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;
  • 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 768 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 768 "Shared Shelter Arrangements" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 768
Bureau of Family Assistance (BFA)
10/19
SHARED SHELTER ARRANGEMENTS
Client
Case
Name:
Number:
Physical
Telephone
Address:
Number:
Mailing
Address:
MEAL ARRANGEMENT FOR FOOD STAMPS
List everyone who lives with you (include all family members and roommates).
Does this person
Is this person’s
Person’s
buy his/her own
Relationship
Telephone
name on the
Name
Signature
Date
food & eat
shelter’s
to you
Number
separately from
(if over age 18)
lease?
you?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
SHELTER ARRANGEMENT—RENT, ROOM, BOARD, HEAT, UTILITIES, TELEPHONE, ETC.
Is your name on the lease for your shelter?
My portion of rent is $
Yes
No
Monthly / Bi-weekly / Weekly
(circle one)
(If yes, please complete BFA Form 775 Rental
Verification Request or provide a copy of the
lease if not on file.)
I am responsible for a portion of the heating costs
I am responsible for telephone costs separate
separate and apart from my rent:
and apart from my rent:
Yes
No
Yes
No
I am responsible for a portion of the electricity
Did you receive fuel assistance in the past 12
costs separate and apart from my rent:
months?
Yes
No
Yes
No
(If yes, please provide copy of approval letter.)
Client Signature
Date
This institution is an equal opportunity provider.
Return to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
BFA SR 19-25
(3YC)
NH Department of Health and Human Services (DHHS)
BFA Form 768
Bureau of Family Assistance (BFA)
10/19
SHARED SHELTER ARRANGEMENTS
Client
Case
Name:
Number:
Physical
Telephone
Address:
Number:
Mailing
Address:
MEAL ARRANGEMENT FOR FOOD STAMPS
List everyone who lives with you (include all family members and roommates).
Does this person
Is this person’s
Person’s
buy his/her own
Relationship
Telephone
name on the
Name
Signature
Date
food & eat
shelter’s
to you
Number
separately from
(if over age 18)
lease?
you?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
SHELTER ARRANGEMENT—RENT, ROOM, BOARD, HEAT, UTILITIES, TELEPHONE, ETC.
Is your name on the lease for your shelter?
My portion of rent is $
Yes
No
Monthly / Bi-weekly / Weekly
(circle one)
(If yes, please complete BFA Form 775 Rental
Verification Request or provide a copy of the
lease if not on file.)
I am responsible for a portion of the heating costs
I am responsible for telephone costs separate
separate and apart from my rent:
and apart from my rent:
Yes
No
Yes
No
I am responsible for a portion of the electricity
Did you receive fuel assistance in the past 12
costs separate and apart from my rent:
months?
Yes
No
Yes
No
(If yes, please provide copy of approval letter.)
Client Signature
Date
This institution is an equal opportunity provider.
Return to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301
BFA SR 19-25
(3YC)