1. (a) An individual who chooses an authorized representative (AR), as defined in He-W 601.01, to help with some or all the responsibilities of applying for or receiving financial assistance for needy families or adult category financial assistance shall provide all of the following information in writing:

   1. (1) The name, address, and telephone number of the AR;
   2. (2) The duties that the AR will carry out, as specified in (c) below;
   3. (3) The individual's relationship to the AR;

   4. (4) A statement signed and dated by the individual acknowledging:

      1. a. The individual’s responsibility for any errors, omissions, or failures to report information to the department of health and human services (department), or inaccurate information reported to the department by the AR;
      2. b. That if the AR uses the individual’s benefits without permission, these benefits will not be replaced by the department;
      3. c. That the person the individual names as the AR will continue to act for the individual until the individual or the AR tells the department of a change; and
      4. d. Comprehension of the individual’s choice of AR and the duties assigned to that AR; and

   5. (5) A statement signed and dated by the AR:

      1. a. Agreeing to accept the responsibilities designated by the individual;

      2. b. Acknowledging that the AR understands that:

         1. 1. Proof of the AR’s identity is required;
         2. 2. If disqualified for a program violation, the person identified as the AR can no longer act as an AR unless there is no one else suitable to represent the individual as described in He-W 603.01(b); and
         3. 3. The AR will continue to act as an AR for the individual until the AR or the individual tells the department of a change.

2. (b) To qualify as an AR, an individual shall be an adult who has:

   1. (1) Expressed concern for the individual's wellbeing;
   2. (2) Sufficient knowledge about the individual's circumstances to assist the individual in applying for or receiving assistance; and
   3. (3) The capability to obtain information about the individual's circumstances.

3. (c) The individual may authorize an AR to carry out one or more of the following responsibilities:

   1. (1) Obtaining department applications and other forms or department paperwork, and completing these for the individual;
   2. (2) Attending eligibility interviews for the individual;
   3. (3) Providing the department with verification of the individual's income, resources, and other case circumstances;
   4. (4) Reporting and verifying changes in the individual's case circumstances to the department;
   5. (5) Receiving the individual's assistance payment, electronic benefits transfer card, and other department mail;
   6. (6) Asking for, attending, and representing the individual at administrative appeals for the individual; and
   7. (7) Any other duties regarding eligibility for financial assistance an individual chooses to designate to an AR.

4. (d) If designated pursuant to (a)(2) above, ARs shall:

   1. (1) Sign department forms completed on behalf of the individual; and
   2. (2) Co-sign department forms they assist the individual in completing.

Source. (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97 New. amd (g)(5) by #6825, eff 8-3-98; ss by #7182, eff 12-24-99, EXPIRED: 12-24-07 New. #9063, eff 1-5-08; ss by #11042, eff 2-24-16; ss by #14380, eff 9-20-25, EXPIRES 9-20-35