BFA Form 811S "Application Summary: Statements of Understanding" - New Hampshire

What Is BFA Form 811S?

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 811S 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 811S "Application Summary: Statements of Understanding" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 811S
Bureau of Family Assistance (BFA)
www.dhhs.nh.gov/dfa/index.htm
01/19
APPLICATION SUMMARY: STATEMENTS OF UNDERSTANDING
INITIALS
All Programs
I certify that I have read “Your Rights and Responsibilities,” and I understand them.
I understand that DHHS will keep my eligibility and case information confidential and only persons
involved in administering DHHS’ programs or as otherwise permitted by Federal regulations or State
law will review it.
I understand that despite other rules of confidentiality, names of children in SNAP (Food Stamp)
and/or FANF households are required to be released to schools so that they may be determined
automatically eligible for Free School Meals.
I understand that I must provide proof of: my household situation, what I have written on the
application, and what I have told DHHS.
I understand that the information I have provided will be verified by collateral contacts and/or
Federal, State, and local officials and that if any information is found to be incorrect or false, or if I
have deliberately withheld information related to my receipt of assistance, now or in the future, I may
lose my benefits and may be prosecuted for fraud.
I understand that my signature below and/or on the application authorizes DHHS and any
contracted third party to obtain verification that I or anyone in my assistance group (AG) meet the
eligibility requirements for assistance, and authorizes release of such information to DHHS. My
authorization to release information to DHHS remains in effect for as long as I or anyone in my AG
receives any kind of DHHS assistance.
I understand that my signature below and/or on the application permits DHHS and any contracted
third party entity to verify my income, identity, and assets, and the income, identity, and assets of
any other person whose income, identity, and assets are required to determine eligibility for the
assistance I am requesting. Failure to give permission to conduct these verifications or revoking
permission to conduct these verifications will result in denial or termination of assistance.
Cash & SNAP (Food Stamp) Programs
I certify that if I applied for FANF, the Domestic Violence Option has been explained to me, and I
understand it.
I certify that if I applied for FANF, I got written information about the treatment of lump sum income.
I understand that my receipt of TANF cash assistance is an assignment to DHHS of each
recipient's rights to child and spousal support.
I understand that if I get cash assistance from DHHS, the cash I get could cause my FS benefits to
end or be reduced. I also understand that if this happens, I will not get advance notice of this
change.
I understand that to get a cash payment from any BFA program, I must be eligible to get that cash
every day of the entire payment period. If I am not eligible for cash at any time during that payment
period, I understand that a cash payment will not be issued to me.
I understand that in NH, if anyone in my household is fleeing to avoid prosecution of a felony crime,
or is violating conditions of probation or parole, that person will be ineligible to get cash or FS
benefits until that individual has satisfied his/her legal obligations with respect to the felony crime or
probation or parole violations. My signature below is my sworn statement that no one in my
household at this time is fleeing felony prosecution or violating conditions of probation or parole.
I understand that the use of my Electronic Benefits Transfer (EBT) card for FS or cash benefits is
controlled by my 4-digit Personal Identification Number (PIN), that I am responsible for the security
of my EBT card and PIN, and that EBT benefits will not be replaced if someone else uses my card
after I have activated it.
I understand that my EBT card or cash from my EBT card cannot be used at stores in which more
than 50% of visible inventory is alcohol, or that primarily engage in body piercing, branding, or
tattooing, gaming establishments, or cigar, pipe, smoke, or tobacco stores/stands/shops, most
marijuana dispensaries, or businesses in which more than 50% of visible inventory being sold or
rented is material considered adult-oriented entertainment per RSA 650:1,III, and that if I use my
EBT card or cash from my EBT card at one of these places, I will be sanctioned with a cash penalty,
per RSA 167:7-b and He-W PART 608.
BFA SR 19-03
(3YC)
PLEASE INITIAL AND SIGN THE BACK!
NH Department of Health and Human Services (DHHS)
BFA Form 811S
Bureau of Family Assistance (BFA)
www.dhhs.nh.gov/dfa/index.htm
01/19
APPLICATION SUMMARY: STATEMENTS OF UNDERSTANDING
INITIALS
All Programs
I certify that I have read “Your Rights and Responsibilities,” and I understand them.
I understand that DHHS will keep my eligibility and case information confidential and only persons
involved in administering DHHS’ programs or as otherwise permitted by Federal regulations or State
law will review it.
I understand that despite other rules of confidentiality, names of children in SNAP (Food Stamp)
and/or FANF households are required to be released to schools so that they may be determined
automatically eligible for Free School Meals.
I understand that I must provide proof of: my household situation, what I have written on the
application, and what I have told DHHS.
I understand that the information I have provided will be verified by collateral contacts and/or
Federal, State, and local officials and that if any information is found to be incorrect or false, or if I
have deliberately withheld information related to my receipt of assistance, now or in the future, I may
lose my benefits and may be prosecuted for fraud.
I understand that my signature below and/or on the application authorizes DHHS and any
contracted third party to obtain verification that I or anyone in my assistance group (AG) meet the
eligibility requirements for assistance, and authorizes release of such information to DHHS. My
authorization to release information to DHHS remains in effect for as long as I or anyone in my AG
receives any kind of DHHS assistance.
I understand that my signature below and/or on the application permits DHHS and any contracted
third party entity to verify my income, identity, and assets, and the income, identity, and assets of
any other person whose income, identity, and assets are required to determine eligibility for the
assistance I am requesting. Failure to give permission to conduct these verifications or revoking
permission to conduct these verifications will result in denial or termination of assistance.
Cash & SNAP (Food Stamp) Programs
I certify that if I applied for FANF, the Domestic Violence Option has been explained to me, and I
understand it.
I certify that if I applied for FANF, I got written information about the treatment of lump sum income.
I understand that my receipt of TANF cash assistance is an assignment to DHHS of each
recipient's rights to child and spousal support.
I understand that if I get cash assistance from DHHS, the cash I get could cause my FS benefits to
end or be reduced. I also understand that if this happens, I will not get advance notice of this
change.
I understand that to get a cash payment from any BFA program, I must be eligible to get that cash
every day of the entire payment period. If I am not eligible for cash at any time during that payment
period, I understand that a cash payment will not be issued to me.
I understand that in NH, if anyone in my household is fleeing to avoid prosecution of a felony crime,
or is violating conditions of probation or parole, that person will be ineligible to get cash or FS
benefits until that individual has satisfied his/her legal obligations with respect to the felony crime or
probation or parole violations. My signature below is my sworn statement that no one in my
household at this time is fleeing felony prosecution or violating conditions of probation or parole.
I understand that the use of my Electronic Benefits Transfer (EBT) card for FS or cash benefits is
controlled by my 4-digit Personal Identification Number (PIN), that I am responsible for the security
of my EBT card and PIN, and that EBT benefits will not be replaced if someone else uses my card
after I have activated it.
I understand that my EBT card or cash from my EBT card cannot be used at stores in which more
than 50% of visible inventory is alcohol, or that primarily engage in body piercing, branding, or
tattooing, gaming establishments, or cigar, pipe, smoke, or tobacco stores/stands/shops, most
marijuana dispensaries, or businesses in which more than 50% of visible inventory being sold or
rented is material considered adult-oriented entertainment per RSA 650:1,III, and that if I use my
EBT card or cash from my EBT card at one of these places, I will be sanctioned with a cash penalty,
per RSA 167:7-b and He-W PART 608.
BFA SR 19-03
(3YC)
PLEASE INITIAL AND SIGN THE BACK!
Cash & SNAP (Food Stamp) Programs Con’t
INITIALS
I understand that if I do not use my FS benefits on my EBT card for 365 days in a row, I will lose
those benefits and not get them back. If I do not use my cash benefits for 90 days in a row, I will lose
those benefits and not get them back. I understand that I will be disqualified from the FS Program and
may be prosecuted if I use my EBT card for illegal purposes. These illegal activities include selling my
card and my PIN for cash, drugs, or other items, or exchanging FS benefits for cash at a retailer.
I understand that for FS benefits, to get a deduction for child care expenses, rent or mortgage
payments, utility or other shelter expenses, child support paid to a non-household member, or medical
expenses (only for the elderly or disabled), I must tell DHHS about these expenses and then provide
proof of them. Failure to report or verify any of the above listed expenses, or of receipt of fuel
assistance, could mean that I will get less FS benefits each month, and will be seen as my statement
that my household does not want to get a deduction for the unreported or unverified expense.
Medical Assistance
I understand that my receipt of medical assistance is an assignment to DHHS of my rights to all third
party medical insurance or payments, including medical child support.
I understand that my receipt of medical assistance means DHHS must be able to obtain medical
records from medical providers. My signature below and/or on the application authorizes my family’s
medical providers to release any records to DHHS.
I understand that, if I am in a nursing home, DHHS must be able to exchange eligibility information
with the nursing home to best administer the program. My signature below and/or on the application
authorizes that exchange and remains in effect for as long as I receive DHHS assistance for my
nursing home care.
I understand that for long-term care services (Nursing Facility or Home and Community-Based Care),
I am required to disclose to DHHS any interest that my spouse or I have in any annuity.
I understand that if either my spouse or I are requesting long-term care services, any annuity
purchased or modified by my spouse or me on or after February 8, 2006 will be considered a transfer
of assets for less than fair market value unless the State is named the beneficiary for at least the
amount of Medicaid paid for long-term care services.
NH Child Care Scholarship
I understand that I must only use child care services paid for by DHHS for those employment-related
activities approved by DHHS. I may have to reimburse DHHS for those payments made for times I
was involved in other, non-approved activities.
Signatures
I certify, under penalty of unsworn falsification pursuant to RSA 641:3, that I have reviewed the above
information and the information summarizing my interview, and it is true and complete to the best of my
knowledge.
Applicant Signature
Date
Signature of Person Helping the Applicant
Date
Relationship to Applicant
I certify that I have given the above signed individual(s) the opportunity to review this document, and that I
have completely explained and given them a copy of the Rights and Responsibilities Notice. I also certify
that I have given them a copy of this page, if it was requested.
Printed Name & Signature
Title/Agency
Date
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