1. (a) Each individual or agency applicant shall complete, sign, date, and submit Form 2609R “Application for Continued Certificate and Enrollment of Communication Access Service Providers” (November 2018 Edition) as provided by DCYF, within 30 days of receipt and provide the following:

   1. (1) A copy of the individual applicant’s licenses to practice communication access services or for agency applicants, a master list that includes the name, type or license and the date of license expiration for each staff member providing communication access services; and
   2. (2) A completed, signed, and dated “State of New Hampshire Alternate W-9” (October 2016 Edition).

2. (b) In addition to the information requested in (a) above, an individual applicant or agency applicant staff member who provides communication access services shall complete, sign, date, and submit Parts B, C, and D that includes the following declaration:

   “I declare that all the information contained above is true, correct and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application”.

3. (c) In addition to the information requested in (a) and (b) above, the individual applicant or agency applicant shall complete, sign, date, and submit Part E “Statement of Affirmation” of Form 2609R “Application for Continued Certification Enrollment of Communication Access Service Providers” (November 2018 Edition), that states:

   “I declare that all the information contained above is true, correct and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application”

4. (d) Providers who fail to submit Form 2609R “Application for Continued Certification and Enrollment of Communication Access Service Providers” (November 2018 Edition) within 30 days of receipt shall have their certification revoked in accordance with He-C 6341.17 and be denied payment.
5. (e) Continuance of certification shall be based on a review and verification of the provider’s compliance with He-C 6341.
6. (f) Review of continued certification compliance shall occur every 3 years from the date of issue.

Source. (See Revision Note at part heading for He-C 6341) #9392, eff 3-1-09, EXPIRED: 3-1-17 New. #12535, INTERIM, eff 5-24-18, EXPIRED: 11-20-18 New. #12684, eff 11-30-18 (formerly He-C 6341.08)