Dfa Form 778 – Fill Out and Use This PDF

The DFA Form 778, issued by the New Hampshire Department of Health and Human Services, Division of Family Assistance, serves as an Authorized Representative Declaration. This form allows individuals applying for or receiving benefits—such as cash, medical aid, Food Stamps, and Child Care assistance—to formally designate someone they trust (like a friend or relative) to help with the application process, attend interviews, complete paperwork, and manage benefits on their behalf. Ensuring the chosen representative understands their responsibilities and the consequences of misuse is an essential part of this process. If you need to designate someone to assist with your benefits, consider filling out the DFA 778 form by clicking the button below.

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DFA 778 PDF Details

Issued by the New Hampshire Department of Health and Human Services (DHHS), Division of Family Assistance, the DFA 778 Authorized Representative Declaration is a formal document that allows clients to appoint a trusted individual to assist with state benefit applications and ongoing case management. This declaration is required whenever a client wants someone else to legally speak, act, or make decisions on their behalf within the benefit system.

The types of state assistance covered by this form include cash benefits, medical assistance, Food Stamps (SNAP), and Child Care support. Any combination of these benefit types can be included in a single authorization, depending on what the client needs. The authorized representative may be a family member, friend, neighbor, or any other person the client trusts. The DHHS does not select or assign representatives. The choice belongs entirely to the client, and no pressure from outside parties is permitted.

Once authorized, the representative may perform a wide range of duties on the client's behalf. These tasks can include attending eligibility interviews, completing and submitting application forms, reporting changes in income, household size, or living circumstances, and receiving benefit notices or correspondence from the DHHS. In some cases, the representative may also be authorized to receive benefits directly on the client's behalf. The form includes a checklist of specific duties, and only those explicitly checked by the client are granted to the representative.

Both the client and the authorized representative must sign the DFA 778 for it to be valid. The client's signature confirms informed consent and understanding of the authorization. The representative's signature confirms their acceptance of the assigned duties and awareness of the legal responsibility involved. The form explicitly states that misrepresentation or misuse of benefits by the representative carries consequences including repayment of overpaid amounts and possible criminal penalties. This mutual accountability structure protects the client's interests throughout the process.

Once completed, the signed form should be submitted to the local DHHS District Office along with the relevant benefit application or case paperwork. Clients should keep a copy for their own records. For related resources, see our general authorized representative form for other types of authorizations, or review available financial assistance applications accepted by New Hampshire agencies. Clients working specifically with SNAP benefits may also find our food stamps fact statement useful when reporting changes.

Question	Answer
Form Name	Dfa Form 778
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	DHHS, dfa 778, dfa form 778, EBT

How to Edit Dfa Form 778 Online for Free

Filling out the DFA 778 form accurately is important for ensuring your authorized representative can act on your behalf without delays or complications. Whether you are completing the form for the first time or updating an existing authorization, the steps below will guide you through the process from start to finish.

Who Needs This Form

This form is required whenever a New Hampshire benefit recipient wants to legally designate another person to assist with their DHHS case. Common situations that call for this authorization include:

Clients who have a disability or health condition that limits their ability to attend appointments or complete paperwork independently
Elderly individuals who need support navigating the benefit application process
Clients who are working full-time and cannot attend scheduled interviews
Individuals with limited English proficiency who rely on a trusted bilingual representative
Anyone temporarily unavailable due to hospitalization, travel, or other circumstances

If any of these situations apply to you, the DFA 778 is the appropriate form for designating your representative under the New Hampshire DHHS benefit system.

Information You Need Before Starting

Before you begin filling out the form, gather the following details to ensure you can complete it in one sitting:

Your full legal name and current mailing address
Your daytime phone number
Your DHHS case number (if you are already receiving benefits)
Your representative's full legal name, home address, and phone number
Your representative's relationship to you (family member, friend, neighbor, etc.)
A clear understanding of which duties you want your representative to perform

Having this information ready beforehand will help you complete the form quickly and reduce the risk of errors that could delay processing.

Step-by-Step Instructions

Enter your personal information. At the top of the form, write your full legal name exactly as it appears on your benefit case file, your current mailing address, and your daytime phone number. If your address has changed recently, use your updated address so the DHHS has current contact information.
Provide your representative's details. In the authorized representative section, enter your representative's full name, their relationship to you, their home address, and a working phone number. Accurate contact information ensures the DHHS can reach your representative if needed for interviews or notifications.
Identify the benefit programs. Check the boxes next to each type of assistance your representative is authorized to handle. The form typically lists cash benefits, medical assistance, Food Stamps (SNAP), and Child Care assistance as separate options. Only check the programs that apply to your situation.
Review and mark authorized duties. The form includes a list of specific tasks the representative may perform. Go through each item carefully and check only the duties you want to grant. Common tasks include attending interviews, submitting applications, reporting household changes, receiving benefit notices, and in some cases managing benefit issuances. Do not check tasks you are not comfortable assigning.
Read the declaration statement. Before signing, read the full declaration text on the form. It outlines that the representative accepts responsibility for accurate reporting and that fraudulent actions or misrepresentation of benefits can lead to repayment demands and criminal penalties. Both parties should understand these terms before proceeding.
Sign and date the client section. In the client signature field, sign your full legal name and write today's date. Your signature confirms that you voluntarily authorize the named representative and that you understand the terms of the declaration.
Have your representative sign and date. Your representative must also sign and date the form in their designated section. Both signatures are required for the authorization to be valid. A form with only one signature will not be accepted by the DHHS.
Submit the completed form. Deliver the signed DFA 778 to your local DHHS District Office in person or by mail. You can also include it with a new benefit application. Always keep a signed copy for your personal records in case any questions arise later.

Common Questions

Can I change my authorized representative after submitting the form?
Yes. You can update your authorized representative at any time by completing a new DFA 778 with the new representative's information. Submit the updated form to your DHHS District Office. The new authorization replaces the previous one once processed.

Can my representative make benefit decisions without asking me first?
Your representative may carry out only the duties you have checked on the form. However, within those duties, they can act independently unless you provide specific instructions otherwise. For this reason, it is important to only check tasks you are comfortable delegating fully.

What if my representative is unavailable or no longer able to help?
If your representative can no longer fulfill their duties, notify your DHHS caseworker as soon as possible. You can revoke the authorization by submitting a written request or a new DFA 778 that cancels the existing one. You may then designate a different representative if needed.

Does the authorized representative need to provide identification?
The DHHS may request identification from your representative during interviews or when they visit a DHHS office on your behalf. Advise your representative to carry a valid government-issued photo ID when acting in their authorized capacity.

For more tools to help with benefit applications and representative designations, browse our authorized representative form templates or explore our library of New Hampshire government forms available for download and online editing.