SR 14-15 Dated 12/14

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases new DFA Form 768, Shared Shelter Arrangements, its Spanish and Nepali versions, and its associated instructions. This form will be given during initial or redetermination interviews to clients sharing living arrangements with other adults over age 18.

Additionally, this SR releases revised DFA Form 808, Proof Needed to Determine Your Assistance, to reflect the additions of DFA Form 768 and the Fuel Assistance award letter as acceptable types of Residence/Shelter verifications.

POLICY

DFA Form 768, Shared Shelter Arrangements

At the request of Field Operations, new DFA Form 768, Shared Shelter Arrangements, was created to formalize a shared shelter form that has been piloted in the District Offices. This form captures information about shared living arrangements and meal arrangements, as well as the client’s share of rent and utilities.

DFA Form 808, Proof Needed to Determine Your Assistance

This form was revised to include new DFA Form 768, Shared Shelter Arrangements, and Fuel Assistance award letter as acceptable types of Residence/Shelter verifications.

NEW HEIGHTS SYSTEMS PROCEDURES AND IMPLEMENTATION

New HEIGHTS will release changes to New HEIGHTS-generated AE0026, Verification Checklist and AE0055, Proof Needed to Determine Your Assistance at a later date under separate cover.

DESCRIPTION OF REVISIONS MADE TO FORMS

DFA FORM 768, SHARED SHELTER ARRANGEMENTS

New DFA Form 768, Shared Shelter Arrangements, is a 1-page, single-sided form used by applicants and recipients living in a shared shelter situation, to document their living, utility, and food sharing arrangements. This form is used to:

·      determine household composition for the Food Stamp Program (FSP);

·      verify shelter costs for the standard utility allowances (SUAs) in the FSP; and

·      verify residency and shelter costs for all programs.

This new form includes fields to capture:

·      client name and identifiers;

·      the client’s meal arrangements with household members over age 18;

·      signatures of household members over age 18;

·      portion of rent and utilities client shares with household members over age 18; and the client’s dated signature.

Note: Fuel assistance additionally needs to be verified with a copy of the fuel assistance award letter.

Instructions for the new form were created accordingly. Additionally, this form is currently being translated into Spanish and Nepali for use in the District Offices, as needed.

All District Offices will be sent an initial supply of the English version of this new form. When that supply is exhausted, orders can be placed via the Quarterly Forms Order (QFO). The Spanish and Nepali versions can be reordered by contacting the Supervisor of the Policy Development Unit. All versions of the forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database. This form is also available on the DHHS website at http://www.dhhs.nh.gov/dfa/forms.htm.

DFA FORM 808, PROOF NEEDED TO DETERMINE YOUR ASSISTANCE

Revised DFA Form 808, Proof Needed to Determine Your Assistance, is a 1-page, double-sided form for all categories of assistance to notify an individual of the types of information and verification required to establish eligibility and of the deadline by which the information or proof is needed. It is the paper backup to New HEIGHTS-generated AE0026, Verification Checklist, and AE0055, Proof Needed to Determine Your Assistance. DFA Form 808 is used only when New HEIGHTS is unavailable.

This form was revised to include new DFA Form 768, Shared Shelter Arrangements, and Fuel Assistance award letter as acceptable Residence/Shelter verifications. Other minor revisions were also made.

Continue to use the old version of DFA Form 808 until the supply is exhausted. The new version of DFA Form 808 will be printed when the current supply is depleted and can be reordered using the QFO, per usual process. The Spanish and Nepali versions can be reordered by contacting the Supervisor of the Policy Development Unit. All versions of the forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

PART 601, TABLE A. 1   FANF Shelter Allowance

Revised Food Stamp Manual Topics

PART 213    Required Verification

PART 601, TABLE J   Shelter Treatment

IMPLEMENTATION

District Offices have been forwarded an initial supply of DFA Form 768. The new version can be used immediately upon receipt. The current version of DFA Form 808 must be used until the supply has been exhausted, at which point the new version will be printed.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned or needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective December 29, 2014. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Family Assistance, Food Stamp, and Forms Manuals.

DFA/SMC:s