Dfa Form 768 PDF Details

In the realm of assisting families and individuals to navigate the complexities of shared living situations, the New Hampshire Department of Health and Human Services (DHHS) introduces the DFA Form 768. Crafted by the Division of Family Assistance (DFA), this crucial document, last updated in August 2017, serves a pivotal role in organizing and clarifying the specifics of shared shelter arrangements. This form not only captures detailed personal information such as client name, physical and mailing addresses, case number, and telephone number but also delves into the intricate aspects of how food and shelter expenses are shared among residents. Individuals are required to list everyone in the household, detailing their relationship, if their names are on the lease, and their food consumption habits to ensure accurate food stamp allocations. Furthermore, the form inquires about the allocation of rent, room, board, heating, utilities, telephone, and even internet service contributions, highlighting the need for transparent communication regarding financial responsibilities within shared living spaces. The DFA Form 768 stands as a testament to the DHHS's commitment to fostering an environment of clarity and support for those in shared living arrangements, aiming to streamline the process of accessing necessary assistance.

QuestionAnswer
Form NameDfa Form 768
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdfa 768, dfa forms 768 or 775, nh shared, nh dfa form 768

Form Preview Example

NH Department of Health and Human Services (DHHS)

DFA Form 768

Division of Family Assistance (DFA)

08/17

SHARED SHELTER ARRANGEMENTS

Client

Name:

Physical Address:

Mailing Address:

Case Number:

Telephone Number:

MEAL ARRANGEMENT FOR FOOD STAMPS

List everyone who lives with you (include all family members and roommates).

 

 

 

 

 

 

 

 

 

 

Is this person’s

 

 

Does this person

 

 

 

Person’s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

buy his/her own

 

 

 

 

 

 

 

 

 

 

 

 

Relationship

 

 

Telephone

 

 

name on the

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

food & eat

 

 

 

Signature

 

 

 

Date

 

 

 

 

to you

 

 

Number

 

 

shelter’s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

separately from

 

 

(if over age 18)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lease?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

you?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHELTER ARRANGEMENT—RENT, ROOM, BOARD, HEAT, UTILITIES, TELEPHONE, ETC.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

∙ Is your name on the lease for your shelter?

 

∙

My portion of rent is $

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Monthly / Bi-weekly / Weekly

 

 

 

 

 

 

(If yes, please complete DFA Form 775 Rental

 

 

 

 

 

 

 

 

(circle one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verification Request or provide a copy of the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lease if not on file.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

∙ I am responsible for a portion of the heating costs

 

∙

I am responsible for telephone costs separate

 

separate and apart from my rent:

 

 

 

 

 

 

 

and apart from my rent:

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

∙ I am responsible for a portion of the electricity

 

∙

Did you receive fuel assistance in the past 12

 

costs separate and apart from my rent:

 

 

 

 

 

 

 

months?

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If yes, please provide copy of approval letter.)

 

 

 

 

 

 

∙ I am responsible for a portion of internet service (including mobile data) separate and apart from rent:

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

Return to: Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301

 

 

 

 

 

 

 

 

DFA SR 17-05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3YC)

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2. Right after filling out this step, go to the next part and fill out the necessary particulars in these blank fields - Yes, Yes, Yes, Yes, Yes, Yes, SHELTER ARRANGEMENTRENT ROOM BOARD, Is your name on the lease for your, Yes, If yes please complete DFA Form, My portion of rent is Monthly, circle one, I am responsible for a portion of, I am responsible for telephone, and Yes.

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