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    Amazing

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    of 3

    NH DEPARTMENT OF

    Department of Health and Human Services HEALTH AND HUMAN SERVICES


    Bureau of Family Assistance
    PO Box 181
    Concord, NH 03302

    August 06, 2024


    ***********************************************************
    Aviso importante acerca de sus beneficios. Por
    favor llame a la Oficina del Distrito si tiene alguna
    duda o pregunta. También puede solicitar servicios
    JOSHUA L ROSA gratuitos de un intérprete.
    WISE UV ***********************************************************
    38 BANK STREET ST
    LEBANON NH 03766

    PROOF NEEDED TO DETERMINE YOUR ASSISTANCE

    You must provide certain proofs before we can tell you if you are eligible for assistance.
    Please read the section below and return all the verifications listed to the address above by
    the due date listed below. You may also bring this information to the District Office or upload
    them to your NH EASY account.

    You will not get the assistance you need or will no longer be eligible for the assistance you are
    currently receiving if we do not get proof of the following items by the deadline below. Your
    assistance will not be denied or closed if you are having trouble getting the proofs and have
    notified us by the date listed below. If you need help getting proof, or don't understand what is
    needed, notify us immediately at the telephone number below. We will assist you in obtaining
    proofs.

    DUE DATE: 08/16/2024

    WE DID NOT RECEIVE PROOF OF:


    The self-employment logs you have provided for April, May, June, and July were all dated
    before the month ended. Please review the enclosed logs making sure all income is reported
    and then update the date on them. Please remember for all upcoming self-employment logs
    need to be dated after the month has ended

    Proof of the items above must be provided by 08/16/2024 or you may not get the
    assistance you need.

    This institution is an equal opportunity provider.

    Case# 528886051 Telephone: (603) 271-9700 or (844) 275-3447 (NH Only)


    ID : AE0056 TDD Access: (800) 735-2964 (NH Only)
    NH Department of Health and Human Services (DHHS) BFA Form 800V
    Bureau of Family Assistance (BFA) 08/23

    EXAMPLES OF ACCEPTABLE PROOFS


    If an interview is required for the assistance you requested, please bring these proofs to your interview.
    Note: An interview is always required for SNAP, and you may be required to provide additional proofs
    after the interview. If an interview is not required and we need proof from you, you will get a separate
    letter from us telling you what proof you need to give us.

    All household members: You must bring the Social Security Number for each household member who is
    applying for assistance, or proof you have applied for one. If someone in your household is not applying for
    benefits they do not have to provide a Social Security Number or prove that they have applied for one. Bring
    some form of ID, like a Driver’s License, work or school ID card, ID from other social services program,
    voter ID card or birth certificate. Also bring your marriage certificate or divorce decree. We need DCSS
    Form s725 for all parents absent from the household.
    Student Status: We need the school schedule for the current term for anyone 16 years or older.
    Health Insurance: All insurance cards for all household members. We do not need copies of your Medicaid
    cards.
    Medical Condition: If you are blind, disabled or temporarily incapacitated, your doctor may need to fill out a
    form. If you are pregnant, bring a letter from your doctor stating your due date.
    Vehicles: We need the registration/title and the amount you owe for any: car, truck, motorcycle, camper,
    snowmobile, or boat.
    Cash Resources: We need current statements including the balance for any: checking/savings account,
    Passbook savings account, Credit Union account, Christmas Club account, stock/bond certificates,
    Certificate of Deposit (CD), trust, IRA/401k, Keogh, mutual fund, medical savings account, and the total
    amount of any cash on hand.
    Life Insurance: We need a copy of the policy and the current face value and cash value.
    Real Estate: We need the following information for any real estate, including your home: deed, mortgage
    (Principal and Interest), reverse mortgage, property tax bill and homeowner’s insurance (Declaration Page).
    Income: Earned Income: 4 weeks of current and consecutive pay stubs, or BFA Form 756. This includes
    on-the-job training, work-study, stipend/grant, VISTA, Summer Youth Program, Senior Citizens Community
    Service, or Census Bureau income.
    If Self-Employed: Profit/Loss worksheet, Schedule C, or other income tax return.
    Unearned Income: Proof of all income from any sources, such as: Supplemental Security Income, Social
    Security (Survivors/Disability/Retirement), child support/alimony (bring all legal documents), adoption
    subsidy/foster care payment, VA pension, other pension, short/long term disability, worker’s compensation,
    unemployment compensation benefits, annuity/trust/401k income, interest/dividends/royalties, rental
    income, railroad or strike benefits.
    Terminated Employment: Letter from your employer stating your last day worked and reason for
    termination and proof of all gross wages paid in the current month, or BFA Form 756.
    Expenses: Rental expense (rent receipt/lease/BFA Form 775/written Shared Shelter Statement or BFA
    Form 768 if you have a roommate you do not eat with), utility expenses (heat/cooling/electric/phone/internet
    including mobile data/Fuel Assistance award letter), child care (receipts/letter from your provider/BFA Form
    476), medical expenses for anyone 60 years and older or disabled (any expense incurred from illness,
    including transportation expenses and adult day care).
    All forms can be found at the District Office or on our website at:
    https://www.dhhs.nh.gov/forms-documents-0
    Questions or concerns can be discussed at your interview.
    Please bring all proofs with you.
    This institution is an equal opportunity provider
    BFA SR 23-27
    (N/A)

    CASE# 528886051

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