SR 23-30 Dated 09/23

 

STATE OF NEW HAMPSHIRE

DEPARTMENT OF HEALTH & HUMAN SERVICES - Bureau of family assistance (bfa)

INTER-DEPARTMENT COMMUNICATION

 

FROM THE OFFICE OF:

Administrator IV of Bureau of Family Assistance (BFA) Debra E. Sorli

BFA SIGNATURE DATE:

September 15, 2023

AT (OFFICE):

Bureau of Family Assistance

TO:

All BFA Staff

All BES Staff

SUBJECT:

Revision made to BFA Forms to Update the Required Nondiscrimination Statement (NDS).

EFFECTIVE DATE:

September 30, 2023

 

SUMMARY

This Supervisory Release (SR) releases revisions made to BFA Forms utilized by the SNAP program to update the Nondiscrimination Statement (NDS). Depending on the type and use of the form, we were able to utilize two versions, a long version and a short version that reads as follows:

1.  Short version for non SNAP specific forms:   

This institution is an equal opportunity provider.

2.    Long version for SNAP specific forms:   

NONDISCRIMINATION STATEMENT

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English.  Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form, which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:

mail:

Food and Nutrition Service, USDA

1320 Braddock Place, Room 334

Alexandria, VA 22314; or

fax:

(833) 256-1665 or (202) 690-7442; or

email:

FNSCIVILRIGHTSCOMPLAINTS@usda.gov

This institution is an equal opportunity provider.

 

POLICY

No policy is being changed by the release of this SR.

 

NEW HEIGHTS & NH EASY SYSTEMS PROCEDURES

·        New HEIGHTS will have the following revised batchable forms available by September 2023: BES Forms 218, 218(Sp), SNAP E&T Log, BFA Forms 11,11(Sp) Authorization to Release Information, BFA Forms 474, 474(Sp), Attestation and Verification of SNAP Household Disaster, BFA Forms 735, 735(Sp), Profit and Loss Statement, BFA Forms 737, 737(Sp), Monthly Self Employment Log, BFA Forms 745, 745(Sp), Statement of Contributions, BFA Forms 768, 768(Sp), Shared Shelter Arrangement, BFA Forms 776, 776(Sp), Client Consent to Grant NH EASY, BFA Forms 778, 778(Sp), Authorized (AR) Representative Declaration, BFA Forms 800R[EFS], 800R[EFS](Sp) EFS Application for Continued Eligibility for SNAP Benefits.

·        NH EASY will also have all of the above mentioned forms including the revised version and newly translated version of BFA Form 800A, 800A(SP), BFA Programs and Services Guide, available in its “Forms” section by September 2023.

·        New HEIGHTS is updating all New HEIGHTS generated letters and notices that contain the Nondiscrimination statement. A “System Release” will be issued once this has been completed.

 

DESCRIPTION OF REVISIONS MADE TO FORMS

All of the following forms have been revised to include the newly updated Nondiscrimination Statement along with minor editorial edits and Spanish translations:

·         BES Forms 218, 218(Sp), 218(i), SNAP E&T Log

o   Instruction sheet name was updated from DFA to BES

·         BFA Forms 11, 11(i), Authorization to Release Information

o   Instruction sheet name was updated from DFA to BFA

o   Now available in to Spanish

·         BFA Forms 63, 63(i), Residence History

·         BFA Forms 474, 474(Sp), 474(i), Attestation and Verification of SNAP Household Disaster

o   Instruction sheet and Spanish translation form name was updated from DFA to BFA

·         BFA Forms 735, 735(Sp), 735(i), Profit and Loss Statement

·         BFA Forms 737, 737(Sp), 737(i), Monthly Self Employment Log

·         BFA Forms 745, 745(Sp), 745(i), Statement of Contributions

·         BFA Forms 758, 758(i), Notice of SS Enumeration

o   Instruction sheet and form name was updated from DFA to BFA

o   Now available in to Spanish

·         BFA Forms 768, 768(Sp), 768(i), Shared Shelter Arrangement

·         BFA Forms 776, 776(i), Client Consent to Grant NH EASY

o   Now available in Spanish

·         BFA Forms 778, 778(i), 778(Sp), Authorized (AR) Representative Declaration

o   Instruction sheet, Spanish translation and form name was updated from DFA to BFA

·         BFA Forms 800A, 800A(Sp), 800A(i), BFA Programs and Services Guide

·         BFA Forms 800R[EFS], 800R[EFS](i), EFS Application for Continued Eligibility for SNAP Benefits

o   Now available in to Spanish

·         BFA Forms 807, 807(i), Interview Appointment Notice (Initial/redetermination/recertification)

o   Instruction sheet name was updated from DFA to BFA

·         BFA Forms 808, 808(i), 808(Sp), Proof Needed to Determine Your Assistance

o   Instruction sheet name was updated from DFA to BFA

 

New versions of the above BES and BFA Forms as well as their Spanish translated version, excluding their instruction sheets will be available electronically on the DHHS website at http://www.dhhs.nh.gov/forms-documents-0  and NH EASY Gateway to Services at https://nheasy.nh.gov/#/forms.

 

Additionally, the following forms will not be available through the Warehouse to order and will be available exclusively electronically on the DHHS website at http://www.dhhs.nh.gov/forms-documents-0 and NH EASY Gateway to Services at https://nheasy.nh.gov/#/forms:

·          BES Forms 218, SNAP E&T Log

·          BFA Forms 11, Authorization to Release Information;

·          BFA Forms 63, Residence History;

·          BFA Form 474, Attestation and Verification of SNAP Household Disaster;

·          BFA Form 758, Notice of SS Enumeration;

·          BFA Forms 776, Client Consent to Grant NH EASY;

·          BFA Forms 807, Interview Appointment Notice (Initial/redetermination/recertification); and

·          BFA Forms 808, Proof Needed to Determine Your Assistance.

 

Place an order through the DHHS Warehouse/Logistics via the District Office’s Quarterly Forms Order (QFO) for all other forms when a supply of the new versions are needed.

 

All of the above BFA Forms will also be available internally, for Department staff only, on the N:\ drive upon release of this SR.

 

THE FOLLOWING FORMS ARE NOW OBSOLETE:

 

·         BFA Form 807R Redetermination-Recertification Interview Appointment Notice

o   This form was previously merged with BFA Form 807, Interview Appointment Notice, and was never obsoleted

·         DFA Forms 77W, 77W(i) Calling about your application

·         DFA Forms 753, 753(i), Veteran Benefit Verification Form

o   New HEIGHTS Generated version is the only one used

·         BFA Form 217, DFA 217(Sp), DFA 217(i), How to Report Changes in Your Case

o   Covers the same information as BFA forms 215 and 470 that are under revision

 

 

POLICY MANUAL REVISIONS

Adult Assistance Manual Topics

PART 103             NONDISCRIMINATION

Family Assistance Manual Topics

PART 103             NONDISCRIMINATION

Food Stamp Manual Topics

PART 103             NONDISCRIMINATION

Medical Assistance Manual Topics

PART 103             NONDISCRIMINATION

 

IMPLEMENTATION

This policy is effective September 30, 2023.

BFA Form 778, Authorized Representative, can continue to be used until current stock is exhausted. All other forms included in this SR MUST BE recycled and the new version used immediately.

A Certificate of Destruction has been included with this SR.

 

CLIENT NOTIFICATION

No special client notification is planned or needed.

 

TRAINING

No special training is planned or needed.

 

FORMS MANUAL POSTING INSTRUCTIONS

 

Remove and Destroy

Insert/Replace

 

DFA Form 77W, Calling About Your Application,

DFA SR 10-38

1 singled sided sheet

None

DFA Form 77W(i), Instructions for Calling About Your Application,

DFA SR 10-38

1 singled sided sheet

None

BFA Form 217, How to Report Changes in Your Case,

BFA SR 19-29

1 singled sided sheet

None

DFA Form 217(Sp), How to Report Changes in Your Case,

DFA SR 12-22

1 singled sided sheet

None

DFA Form 217(i), How to Report Changes in Your Case,

DFA SR 12-22

1 singled sided sheet

None

DFA Form 753, VA Benefit Verification Form,

DFA SR 86-20

1 singled sided sheet

None

DFA Form 753(i), Instructions for VA Benefit Verification Form,

DFA SR 86-20

1 singled sided sheet

None

BES Form 218, SNAP E&T Activity Log

BFA SR 22-33

1 double sided sheet

BES Form 218, SNAP E&T Activity Log

BFA SR 23-30

1 double sided sheet

BES Form 218(Sp), SNAP E&T Activity Log

BFA SR 22-33

1 double sided sheet

BES Form 218(Sp), SNAP E&T Activity Log

BFA SR 23-30

1 double sided sheet

DFA Form 218(I), Instructions for SNAP E&T Activity Log

DFA SR 16-04

1 double sided sheet

BFA Form 218(I), Instructions for SNAP E&T Activity Log

BFA SR 23-30

1 double sided sheet

BFA Form 11, Authorization to Release Information

BFA SR 19-29

1 singled sided sheet

BFA Form 11, Authorization to Release Information

BFA SR 23-30

1 singled sided sheet

DFA Form 11(i), Instructions for Authorization to Release Information

DFA SR 12-30

1 singled sided sheet

BFA Form 11(i), Instructions for Authorization to Release Information

BFA SR 23-30

1 singled sided sheet

None

BFA Form 11(Sp), Authorization to Release Information

BFA SR 23-30

1 singled sided sheet

BFA Form 63, Residency History

BFA SR 22-35

1 singled sided sheet

BFA Form 63, Residency History

BFA SR 23-30

1 singled sided sheet

BFA Form 63(i), Instructions for Residency History

BFA SR 22-35

1 singled sided sheet

BFA Form 63(i), Instructions for Residency History

BFA SR 23-30

1 singled sided sheet

BFA Form 474, Attestation and Verification of Food Stamp Households Disaster

BFA SR 19-29

1 double sided sheet

BFA Form 474, Attestation and Verification of SNAP Households Disaster

BFA SR 23-30

1 double sided sheet

DFA Form 474(Sp), Attestation and Verification of SNAP Households Disaster

DFA SR 17-10

1 double sided sheet

BFA Form 474(Sp), Attestation and Verification of SNAP Households Disaster

BFA SR 23-30

1 double sided sheet

DFA Form 474(i), Instructions for Attestation and Verification of SNAP Households Disaster

DFA SR 15-30

1 double sided sheet                 

BFA Form 474(i), Instructions for Attestation and Verification of SNAP Households Disaster

BFA SR 23-30

1 double sided sheet

BFA Form 735, Profit and Loss Statement for Self Employment

BFA SR 22-35

1 single sided sheet

BFA Form 735, Profit and Loss Statement for Self Employment

BFA SR 23-30

1 single sided sheet

BFA Form 735(Sp), Profit and Loss Statement for Self Employment

BFA SR 22-35

1 single sided sheet

BFA Form 735(Sp), Profit and Loss Statement for Self Employment

BFA SR 23-30

1 single sided sheet

BFA Form 735(i), Instructions for Profit and Loss Statement for Self Employment

BFA SR 22-35

1 double sided sheet

BFA Form 735(i), Instructions for Profit and Loss Statement for Self Employment

BFA SR 23-30

1 double sided sheet

BFA Form 737, Monthly Self Employment log

BFA SR 22-35

1 single sided sheet

BFA Form 737, Monthly Self Employment log

BFA SR 23-30

1 single sided sheet

BFA Form 737(Sp), Monthly Self Employment log

BFA SR 22-35

1 single sided sheet

BFA Form 737(Sp), Monthly Self Employment log

BFA SR 23-30

1 single sided sheet

BFA Form 737(i), Instructions for Monthly Self Employment log

BFA SR 22-35

1 double sided sheet

BFA Form 737(i), Instructions for Monthly Self Employment log

BFA SR 23-30

1 double sided sheet

BFA Form 745, Statement of Contributions

BFA SR 22-35

1 single sided sheet

BFA Form 745, Statement of Contributions

BFA SR 23-30

1 single sided sheet

BFA Form 745(Sp), Statement of Contributions

BFA SR 22-35

1 single sided sheet

BFA Form 745(Sp), Statement of Contributions

BFA SR 23-30

1 single sided sheet

BFA Form 745(i), Instructions for Statement of Contributions

BFA SR 22-35

1 single sided sheet

BFA Form 745(i), Instructions for Statement of Contributions

BFA SR 23-30

1 single sided sheet

DFA Form 758, Notice of SS Enumeration

DFA SR 97-08

1 single sided sheet

BFA Form 758, Notice of SS Enumeration

BFA SR 23-30

1 single sided sheet

None

BFA Form 758(Sp), Notice of SS Enumeration

BFA SR 23-30

1 single sided sheet

DFA Form 758(i), Instructions for Notice of SS Enumeration

DFA SR 97-08

1 single sided sheet

BFA Form 758(i), Instructions for Notice of SS Enumeration

BFA SR 23-30

1 single sided sheet

BFA Form 768, Shared Shelter Statement

BFA SR 22-29

1 single sided sheet

BFA Form 768, Shared Shelter Statement

BFA SR 23-30

1 single sided sheet

BFA Form 768(Sp), Shared Shelter Statement

BFA SR 22-29

1 single sided sheet

BFA Form 768(Sp), Shared Shelter Statement

BFA SR 23-30

1 single sided sheet

BFA Form 768(i), Instructions for Shared Shelter Statement

BFA SR 22-29

1 double sided sheet

BFA Form 768(i), Instructions for Shared Shelter Statement

BFA SR 22-29

1 single sided sheet

BFA Form 776, Client Consent to Grant NH EASY Access

BFA SR 19-29

1 double sided and 1 single sided sheet

BFA Form 776, Client Consent to Grant NH EASY Access

BFA SR 23-30

1 double sided and 1 single sided sheet

None

BFA Form 776(Sp), Client Consent to Grant NH EASY Access

BFA SR 23-30

1 double sided sheet

DFA Form 776(i), Instructions for Client Consent to Grant NH EASY Access

DFA SR 16-24

1 double sided sheet

BFA Form 776(i), Instructions for Client Consent to Grant NH EASY Access

BFA SR 23-30

1 double sided sheet

DFA Form 778, Authorized Representative Declaration

DFA SR 17-07

1 double sided sheet

BFA Form 778, Authorized Representative Declaration

BFA SR 23-30

1 double sided sheet

DFA Form 778(Sp), Authorized Representative Declaration

DFA SR 17-07

1 double sided sheet

BFA Form 778(Sp), Authorized Representative Declaration

BFA SR 23-30

1 double sided sheet

DFA Form 778(i), Authorized Representative Declaration

DFA SR 16-24

1 double sided sheet

BFA Form 778(i), Authorized Representative Declaration

BFA SR 23-30

1 single sided sheet

BFA Form 800A, BFA Programs and Service Guide

BFA SR 22-37

3 double side sheets

BFA Form 800A, BFA Programs and Service Guide

BFA SR 23-30

3 double side sheets

BFA Form 800A(Sp), BFA Programs and Service Guide

BFA SR 22-37

4 double side and 1 single sided sheet

BFA Form 800A(Sp), BFA Programs and Service Guide

BFA SR 23-30

3 double side

BFA Form 800A(i), Instructions for BFA Programs and Service Guide

BFA SR 22-37

1 single sided sheet

BFA Form 800A(i), Instructions for BFA Programs and Service Guide

BFA SR 23-30

1 single sided sheet

BFA Form800R[EFS], Extended Food Stamp (EFS) Application for Continued Eligibility

BFA SR 20-07

2 double side and 1 single sided sheet

BFA Form800R[EFS], Extended Food Stamp (EFS) Application for Continued Eligibility

BFA SR 23-30

2 double side and 1 single sided sheet

None

BFA Form800R[EFS](Sp), Extended Food Stamp (EFS) Application for Continued Eligibility

BFA SR 23-30

2 double side and 1 single sided sheet

BFA Form800R[EFS](i), Instructions for Extended Food Stamp (EFS) Application for Continued Eligibility

BFA SR 20-07

1 double side sheet

BFA Form800R[EFS](i), Instructions for Extended Food Stamp (EFS) Application for Continued Eligibility

BFA SR 23-30

1 single side sheet

BFA Form 807, Interview Appointment Notice

BFA SR 19-29

1 single and 1 double sided sheet

BFA Form 807, Interview Appointment Notice

BFA SR 23-30

1 single and 1 double sided sheet

DFA Form 807, Instructions for Interview Appointment Notice

DFA SR 94-16

1 single sided sheet

BFA Form 807, Instructions for Interview Appointment Notice

BFA SR 23-30

1 single sided sheet

BFA Form 808, Proof Needed to Determine Your Assistance

BFA SR 20-07

1 double sided sheet

BFA Form 808, Proof Needed to Determine Your Assistance

BFA SR 23-30

1 single and 1 double sided sheet

BFA Form 808(Sp), Proof Needed to Determine Your Assistance

BFA SR 19-25

1 single and 1 double sided sheet

BFA Form 808(Sp), Proof Needed to Determine Your Assistance

BFA SR 23-30

1 single and 1 double sided sheet

DFA Form 808(i), Proof Needed to Determine Your Assistance

DFA SR 14-15

1 double sided sheet

BFA Form 808(i), Proof Needed to Determine Your Assistance

BFA SR 23-30

1 single sided sheet

 

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 Online Manuals.

 

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for BFA policy releases. This SR, and revised Online Manuals, will be available for agency staff in the Online Manual Library, and for public access on the Internet at https://www.dhhs.nh.gov/sr_htm/sr.htm, effective October 2, 2023.

 

BFA:rs

 

 

CERTIFICATE OF DESTRUCTION

I certify that all copies and versions of the BES and BFA Forms indicated to be destroyed in BFA SR 23-30 have been successful destroyed.

District Office Administrative Supervisor:   _________________________________________

District Office:   ______________________________________________________________

Return this certificate to the BFA Policy Unit, 129 Pleasant St, Brown Bldg, 3rd Floor, Concord, NH 03301, after the instructions in the SR have been carried out.