Dfa Form 778 – Fill Out and Use This PDF

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.