BFA Form 811R "Application: Your Rights and Responsibilities" - New Hampshire

What Is BFA Form 811R?

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 January 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 811R 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 811R "Application: Your Rights and Responsibilities" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 811R
Bureau of Family Assistance (BFA)
www.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 (Food Stamp) 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 (Food Stamp) case could be closed,
Notice to Immigrant Families
and/or your eligibility for Medical Assistance may be
affected, if you do not completely fill out the form and
If you get help with health care or SNAP, it will not
return it 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 (Food Stamp) benefits and you
have a 4, 5, or 6-month eligibility period, you only
become U.S. citizens.
need to report those changes in household
However, if you get cash assistance such as TANF
circumstances that would place your household’s
or help with the cost of nursing home care, it might
income above 130% 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;
NH Department of Health and Human Services (DHHS)
BFA Form 811R
Bureau of Family Assistance (BFA)
www.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 (Food Stamp) 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 (Food Stamp) case could be closed,
Notice to Immigrant Families
and/or your eligibility for Medical Assistance may be
affected, if you do not completely fill out the form and
If you get help with health care or SNAP, it will not
return it 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 (Food Stamp) benefits and you
have a 4, 5, or 6-month eligibility period, you only
become U.S. citizens.
need to report those changes in household
However, if you get cash assistance such as TANF
circumstances that would place your household’s
or help with the cost of nursing home care, it might
income above 130% 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;
ATTENTION!
Anything you tell or give to us will be verified:
at the federal, state and local levels; and also
through collateral contacts and/or computer matching with other electronic verification tools such as, but not
limited to, USCIS, IEVS, Vital Records, SSA, financial institutions, & employment databases.
We do this to confirm your eligibility for our programs and determine your benefits. If any information we get from
using these sources doesn’t match the information you provided to us, you may be denied assistance, your
benefits may change, and you may be subject to criminal prosecution for knowingly providing false information.
Any member of your household who breaks any of these rules on purpose can be prohibited from participating in
the cash assistance, child care assistance, and SNAP (Food Stamp) programs for periods ranging from one year to
permanently. In the SNAP (Food Stamp) Program, you can also be fined up to $250,000, imprisoned up to 20 years,
or both, and will be subject to prosecution under the applicable state and federal laws for violations of the Food
Stamp Act. If you are convicted, the court may also bar you from participating in the program for another 18
months, in addition to the sentence you receive.
benefits of more than $500, will become permanently
DO NOT
ineligible for FS benefits.
Do not give false information or hide information to
For buying or selling FS benefits will be suspended
get or continue to get benefits.
st
from the FS Program for 1 year for the 1
offense, 2
Do not trade or sell SNAP benefits (Food Stamps) to
nd
rd
years for the 2
offense, and permanently for the 3
.
anyone who is not authorized to use them for your
Medical Assistance Fraud
household.
Section 1128B of the Social Security Act provides federal
Do not use FS benefits to buy ineligible items.
penalties for fraudulent acts and false reporting in
Do not use any benefits your household was not
connection with your application for or receipt of Medical
entitled to receive.
Assistance benefits.
Do not give your EBT Card PIN out to anyone.
A person may be prosecuted in Federal Court for
Do not use child care services paid for by DHHS, for
deliberate statements that are known to be false and
employment-related activities not approved by
which affect eligibility for any benefit or payment under the
DHHS.
Medical Assistance program.
Do not use your EBT card or cash from your EBT
A person may also be prosecuted for concealing or failing
card at stores in which more than 50% of visible
to disclose any event that affects their right to any benefit
inventory is alcohol, or that primarily engage in body
or payment, or its conversion to a use other than intended.
piercing,
branding,
or
tattooing,
gaming
The law also provides a penalty for a kickback, bribe, or
establishments, cigar, pipe, smoke, or tobacco
rebate in connection with the furnishing of Medical
stores/stands/shops, most marijuana dispensaries, or
Assistance.
businesses in which more than 50% of visible
Conviction of an offense could result in loss of Medical
inventory being sold or rented is adult-oriented
Assistance benefits for a period not to exceed 1 year.
entertainment.
Penalties are fines up to $25,000 or imprisonment for not
Do not try to buy food with your FS benefits unless
more than 5 years, or both.
you have your EBT card with you at the time you buy
the food. You may not buy food on 1 day and pay for
Intentional False Statements/Program Violations (IPV)
it with your EBT FS benefits on another day.
Any person who intentionally makes a false statement or
Identity & Residence
misrepresents his or her circumstances or intentionally
fails to disclose the receipt of property, wages, income or
An individual who DHHS has determined has made or is
resources or any change in circumstances that would
convicted of having made a fraudulent statement or
affect his or her initial or continued eligibility for assistance
representation with respect to the identity or place of
may be found guilty of violating state law. The penalties
residence in order to receive multiple benefits at the same
are: a class A felony where the value of the monetary
time will be ineligible for financial assistance and SNAP
award or goods or services exceeds $1,000; a class B
(Food Stamp) benefits for 10 years.
felony
where
the
value
exceeds
$100;
and
a
Trafficking SNAP Benefits (Food Stamps)
misdemeanor where the value does not exceed $100.
Any person who is found guilty in a court of law:
RSA 167:17-b and 17-c.
Anyone who commits an intentional program
Of trading of a controlled substance in exchange for FS
violation (IPV) in the SNAP (Food Stamps) cannot get
benefits, will be prohibited from participating in the FS
st
these benefits for 12 months for the 1
violation, 24
Program for 24 months for the 1st offense and
nd
rd
months for the 2
violation, and permanently for a 3
permanently for the 2nd offense.
IPV.
For the trading of ammunition, firearms, or explosives
in exchange for FS benefits, or of any trafficking in FS
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