If you are a citizen or permanent resident of the United States, you may be required to complete a DFA Form 778 when you file your U.S. tax return. This form is used to certify your foreign assets and income, and it is important that you complete it accurately and truthfully. If you fail to report your foreign assets or income, you could face penalties from the IRS. For more information on the DFA Form 778, please contact our office today. We would be happy to help you get started on filing your taxes correctly this year.
| 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 |
NH Department of Health and Human Services (DHHS) |
DFA Form 778 |
Division of Family Assistance (DFA) |
05/12 |
AUTHORIZED REPRESENTATIVE DECLARATION
You may choose an authorized representative to help you with some or all of the requirements of applying for or getting benefits. These benefits include: cash, medical, Food Stamps, and/or Child Care assistance.
An authorized representative is a friend, relative or other person who has a concern for your
An authorized representative may go to interviews for you. They may fill out an application form and other paperwork for you. They may also report changes in your income, resources, and other changes for you. They may receive your Electronic Benefits Transfer (EBT) card, medical assistance ID card, and other mail from us. You get to choose what you would like them to do for you or on your behalf by checking the boxes below.
AUTHORIZED REPRESENTATIVE DUTIES
Check off the things that you want the authorized representative to do for you:
Get my application, forms and other Department paperwork, and fill these forms out for me.
Provide the Department with proof of my income, resources, and other case information, and report and verify changes in my case circumstances to the Department for me.
Receive my notices from the Department.
Receive my EBT Card in their name.
Receive my EBT Card for me.
Receive my medical assistance ID card for me.
Other:
Receive my cash benefits for me.
Go to my eligibility interviews for me.
CLIENT’S SIGNATURE
Please read the following statements carefully. Your signature below means you have read, understand, and accept these statements.
•I certify that I have read and understand the information on this form.
•I understand that I am responsible for any errors, omissions, or inaccurate information that my authorized representative reports to the District Office.
•I understand that if my authorized representative uses my benefits without my permission, these benefits will not be replaced or reissued by the Department of Health and Human Services.
•I understand that the person I named as my authorized representative will continue to act for me unless I tell the Department in writing of a change.
Client’s Signature |
Date |
Client’s Printed Name
(Please Turn Over)
DFA SR
(A)
AUTHORIZED REPRESENTATIVE INFORMATION
Tell us your authorized representative’s name, address, and telephone number. Please print clearly.
First Name |
Middle Initial |
Last Name |
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Street/Mailing Address |
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Telephone Number |
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City, State, and Zip Code |
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Alternate Telephone Number |
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Date of Birth |
Describe your relationship to the authorized representative. |
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(Optional) |
(If your authorized representative is a member of an agency, write the name of the |
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agency here.) |
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AUTHORIZED REPRESENTATIVE’S SIGNATURE
I certify that I have read and understand the information on this form. I agree to accept the duties noted on this form and understand the following:
•I understand that I must give proof of my identity to act as an Authorized Representative.
•I understand that if I have been disqualified for a program violation, I cannot act as an Authorized Representative unless there is no one else suitable to represent this individual.
•I understand that the Department has the authority to discontinue my ability to act as an Authorized Representative if it is determined that I am not acting in the best interest of the household I am assisting.
•I understand that if I am an Authorized Representative for a Food Stamp recipient in a drug and alcohol treatment center or other group living arrangement, and I give erroneous information which leads to an
Authorized Representative’s Signature |
Date |
Authorized Representative’s Printed Name