Dfa Form 756 PDF Details

Understanding the NH Department of Health and Human Services' BFA Form 756 is crucial for both employers and employees engaged in the verification of employment status. This comprehensive form, issued by the Bureau of Family Assistance (BFA), plays a pivotal role in documenting employment details precisely for the purposes of eligibility assessments for various health and human services programs. Designed for completion exclusively by employers, it covers an extensive range of employment information, from basic details like the employee’s name, Social Security Number (SSN), and job title, to more specific data including rate of pay, hours worked per week, and any deductions such as retirement funds, medical insurance, or child support arrangements. The form also addresses changes in employment status, such as terminations or leaves of absence, providing a section for employers to detail reasons for employment ending, alongside data on final paychecks or severance pay. Furthermore, it requests information on any additional income that might not be included in the gross wages, like bonuses, tips, or commissions. Ensuring accuracy and completeness when filling out the DFA 756 form is not only a legal requirement but also a contribution to the efficient processing of vital assistance applications, reinforcing the collective effort to support individuals and families in need.

QuestionAnswer
Form NameDfa Form 756
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnh dhhs form employment, dhhs form 756, nh dhhs form, bfa form 756

Form Preview Example

 

NH Department of Health and Human Services (DHHS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BFA Form 756

 

Bureau of Family Assistance (BFA)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/19

 

 

Employment Verification (Completed by Employer Only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM:

 

 

 

 

 

 

Eligibility Worker Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Centralized Scanning Unit (CSU)

 

 

 

 

 

 

 

Telephone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P.O. Box 181

 

 

 

 

 

 

 

 

 

Today’s Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Concord, NH 03301

 

 

 

 

 

 

 

Please complete and return by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR CURRENT EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employee:

 

 

 

 

 

 

 

 

 

 

 

 

SSN:

 

-

 

 

 

 

 

 

-

 

 

 

 

Date of Hire:

 

 

 

 

 

 

 

 

 

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Av. Hrs per Week:

 

 

 

 

 

 

 

Current Rate of Pay: $

 

 

 

 

 

 

per

 

 

 

 

 

 

EIN:

 

 

If this is new employment, the date of the 1st paycheck:

 

 

 

 

 

 

 

Frequency of pay: (circle one)

Weekly

 

Bi-weekly

Monthly

Semi-monthly

 

 

 

 

 

 

Please indicate if the employee has any of the following deductions:

 

 

 

Credit Union Account(s)

 

 

 

 

Share/Profit Sharing

 

 

 

 

Retirement Fund/IRA

 

 

 

Mandatory Wage Assignment

 

 

Medical Insurance:

 

 

 

 

Savings Bond(s)

 

 

 

(i.e., Child Support Assignment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you anticipate any changes in rate of pay or hours?

Yes (use back of form to explain)

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR TERMINATED EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employee:

 

 

 

 

 

 

 

 

 

 

 

 

SSN:

 

-

 

 

 

 

 

 

-

 

 

 

 

Date of Termination or Leave of Absence:

 

 

 

 

 

CIRCLE ONE: Permanent

 

 

Temporary

 

Reason for Termination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual Date Final Paycheck Received:

 

 

 

 

 

 

 

Gross Amount of Final Paycheck:

 

 

 

 

 

 

 

Did the employee receive money from any other sources?

Y

N If yes, please indicate source,

 

 

 

type, & amount (i.e., severance pay, worker’s comp, etc.):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did the employee have medical insurance?

Y

N

End Date?

 

 

 

 

COBRA Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE THIS SECTION FOR BOTH CURRENT AND TERMINATED EMPLOYMENT Please list the employee’s gross wages for the last 4 weeks, and indicate all bonuses, tips, or commissions

that are not already included in the gross wages. If the employee receives an Earned Income Tax Credit (EITC), indicate the amount of the credit.

If not already included in Gross Wages…

Actual Date Paid Gross Wages

EITC

# of Hours

Tips

Bonus

Commission

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Information Requested by the Department:

Yes, see back of form for more details

No

Signature & Title of Person Completing this Form

Company

Company Address

Thank you for your cooperation.

This institution is an equal opportunity provider.

Date

Telephone Number

Fax Number

BFA SR 19-29 (3YC)

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1. When filling out the bfa form 756, make certain to complete all of the important blanks within its associated section. This will help to hasten the work, allowing for your information to be processed without delay and properly.

How one can prepare nh 756 form part 1

2. The subsequent part is to submit the following blanks: Reason for Termination, Actual Date Final Paycheck Received, Gross Amount of Final Paycheck, Did the employee receive money, If yes please indicate source, type amount ie severance pay, Did the employee have medical, End Date, COBRA, COMPLETE THIS SECTION FOR BOTH, Please list the employees gross, Actual Date Paid Gross Wages, EITC, of Hours, and Additional Information Requested.

Completing part 2 of nh 756 form

It is easy to make errors while filling in your End Date, therefore be sure to go through it again prior to when you send it in.

Step 3: Make certain the information is accurate and press "Done" to progress further. Acquire your bfa form 756 when you join for a 7-day free trial. Readily view the pdf file inside your personal account page, along with any modifications and adjustments being all preserved! Here at FormsPal, we endeavor to make certain that your details are stored protected.

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