1. (a) The applicant, a person assisting the applicant, or an individual acting on the applicant’s behalf shall apply and be deemed eligible to receive Title XX services via an application form provided by the department entitled Form 3000, “Application for Social Services” (June 2025).
2. (b) An application for Title XX services shall be completed, signed, and dated by the applicant, an individual assisting the applicant, or an individual acting on the applicant’s behalf, and submitted to the department or the contract agency, depending on where the determination of eligibility is being made.

3. (c) The applicant, the individual assisting the applicant, or the individual acting on the applicant’s behalf shall certify the following:

   1. (1) If the application is signed by the applicant:

      “I have read and understood the information on the application, including the Assurances section on the next page, and I agree that the entries I have made on this application are true and accurate to the best of my knowledge.”

      “I understand that as part of the administration of Bureau of Adult and Aging Services (BAAS) programs, BAAS, or an agency under contract with BAAS, may verify information I have provided on this application and any other information that would affect my eligibility.”

      “My signature below authorizes BAAS and the contract agency to obtain verification and authorized release of such information to BAAS and the contract agency. My authorization to release information remains in effect until the time of my next redetermination of eligibility.”

      “I understand that I must report any change in my address or income to the DHHS district office or contract agency where I applied for services, since such changes may affect my eligibility for services.”

   2. (2) If the application is signed by an individual assisting the applicant or by an individual acting on the applicant’s behalf:

      “My signature below indicates that I have completed this form on behalf of the applicant, using information provided by the applicant, and that this information is true and complete to the best of my knowledge. I also certify that I have read the signatures section above. The applicant acknowledges that they may be responsible for any errors, omissions or inaccurate information reported to BAAS by me while assisting them.”

4. (d) If information needed to determine eligibility, as described in He-E 501.05, is incomplete or missing, the provider shall immediately notify the applicant.
5. (e) The applicant shall provide the missing information to the department or the provider within 10 days of the face-to face interview.
6. (f) If the applicant does not provide the missing information within the allotted time as stipulated in (e) above, the applicant’s application shall be denied.
7. (g) An application shall not be required prior to the applicant receiving Title XX services when the department determines services are needed for protective reasons in accordance with RSA 161-F:42-57.

8. (h) Income shall be verified as described in (i) below and for the following reasons:

   1. (1) There is an indication that the income information provided by the applicant or an individual acting on behalf of the applicant is inaccurate; or
   2. (2) The department performs an audit to verify income for quality control purposes.

9. (i) At the request of the department or the provider, when determining eligibility, the applicant or an individual acting on behalf of the applicant shall verify income by providing the following information:

   1. (1) Current pay stubs or employer statements, when income includes wages;
   2. (2) Current business records, when the applicant is self-employed;
   3. (3) A copy of the benefit check dated within the last 30 days or the most recent letter from the Social Security administration, when income includes Social Security benefits or Supplemental Security income, or a copy of the most current bank statement showing that the Social Security or Supplemental Security income check has been direct-deposited;
   4. (4) A copy of the benefit check dated within the last 30 days or the most recent correspondence from the agency, business, or union that indicates benefit amounts, when income includes workers’ compensation;
   5. (5) A copy of the pension check dated within the last 30 days or the most recent correspondence from the appropriate agency, business, or union, when income includes a pension;
   6. (6) Bank statements dated within the last 30 days, or the most recent stockholder report when income includes interest from income, dividends, trusts, estates, or royalties;
   7. (7) A copy of a check received from the tenant or boarders dated within the last 30 days or the most current copy of the rental or room and board agreement, when income includes money received from rents, room and board, or rental of land;
   8. (8) A copy of the benefits check dated within the last 30 days or the most recent notice indicating the amount of benefits awarded, when income includes unemployment compensation;
   9. (9) A copy of the most recent court order or a signed statement from the individual making the payment, when income includes alimony; and
   10. (10) A copy of the benefit check dated within the last 30 days or the most recent notice indicating the amount of benefits awarded, when income includes veterans benefits.
10. (j) If requested by an individual, the department or the provider shall assist the individual with completing the application.

Source. #9849-A, eff 1-12-11, (paras (c)-(i)); #9849-B, eff1-12-11, (paras (a) and (b)); (c)-(i) EXPIRED: 1-12-19; ss by #12720, INTERIM, eff 1-29-19, EXPIRED: 7-29-19 New. #12936, eff 12-7-19; ss by #14298, eff 7-1-25, EXPIRES: 7-1-35