SR 04-09 Dated 08/04

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases:

·      new Form 77s, What Are Liens and Estate Claims?, and its instructions; and

·      revised Form 757, How Your Benefits Will Change When You Go To Work!.

In addition, this SR obsoletes Form EFT-R(Sp), Information Required to Process Electronic Funds.

FORMS

New Form 77s, What Are Liens and Estate Claims?

New Form 77s, What Are Liens and Estate Claims?, gives a general overview of liens and estate claims as they pertain to repayment of Old Age Assistance (OAA) and Aid to the Permanently and Totally Disabled (APTD) financial and medical assistance. It is a one-page double sided, 4-panel pamphlet designed in a question and answer format.

Form 77s was developed to educate OAA and APTD cash and medical assistance recipients on the basic principles of liens and estate claims as well as to help answer the most frequently asked questions. Provide Form 77s to all applicants for OAA or APTD financial and medical assistance at the initial eligibility interview when providing Form 770, Reimbursement Agreement and Acknowledgment, and upon client request.

District Offices will receive a supply of Form 77s, What Are Liens and Estate Claims?, when logistics receives the initial printing order from Graphic Services.

Revised Form 757, How Your Benefits Will Change When You Go To Work!

Form 757, How Your Benefits Will Change When You Go To Work!, has been revised to:

·      align text with current reporting requirements policy; and

·      adjust the formatting and color scheme.

In addition, examples that contained income and benefit allotment figures were eliminated in an effort to cut costs involved in updating Form 757 annually.

District Offices will continue to use existing supplies of Form 757 until stocks are depleted. At that time, the revised version of Form 757 released by this SR may be ordered in accordance with normal ordering procedures.

Obsolescence of Form EFT-R(Sp), Information Required to Process Electronic Funds

This SR obsoletes Form EFT-R(Sp), Information Required to Process Electronic Funds. Form EFT-R(Sp) is the Spanish language version of Form EFT-R, Information Required to Process Electronic Funds Transfer (EFT) – Recipient, which was obsoleted in SR 04-03/May, 2004. The obsolescence of Form EFT-R(Sp) was inadvertently overlooked during the release of SR 04-03.

IMPLEMENTATION

Form 77s, What Are Liens and Estate Claims?, may be used upon receipt.

Continue using Form 757, How Your Benefits Will Change When You Go To Work!, until supplies are exhausted, at which time the version released in this SR will be ordered.

Destroy any existing stock of Form EFT-R(Sp), Information Required to Process Electronic Funds.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned or necessary.

FORMS POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the SR has been posted to the On-Line Manual.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. It will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at http://www.dhhs.nh.gov/DHHS/DFA/LIBRARY, effective August 30, 2004.

This SR will be distributed under separate cover to all hard copy holders of the Forms Manual.

DFA/DMS:s

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CERTIFICATE OF DESTRUCTION

I certify that all copies of Form EFT-R(Sp), Information Required to Process Electronic Funds, dated 9/02, SR 02-34, have been destroyed.

Office Manager:    District Office     

Return this certificate to DHHS Stock Control, 29 Hazen Drive, Concord, NH 03301, after the instructions in the SR have been carried out.