1. (a) Pursuant to RSA 167:28, each applicant for old age assistance (OAA), aid to the needy blind (ANB), or aid to the permanently and totally disabled (APTD) financial assistance, as well as the spouse of the applicant if residing with the applicant, shall complete an agreement to reimburse the federal government, the state, and the county for all assistance granted.

2. (b) The agreement required in (a) above shall include:

   1. (1) The printed name of the applicant;
   2. (2) The printed name of the applicant’s spouse, if applicable;
   3. (3) The applicant’s street address;
   4. (4) The county where the applicant resides;
   5. (5) The physical location where the agreement is being signed;
   6. (6) The dated signature of the applicant, and spouse if applicable;
   7. (7) The dated signature of a notary public or justice of the peace;
   8. (8) The date the commission of the notary public or justice of the peace expires;
   9. (9) The raised seal if witnessed by a notary public; and
   10. (10) Acknowledgement that the department has advised the applicant of the requirements of RSA 167:16-a, if applicable.
3. (c) If an applicant or spouse fails to complete and sign the agreement, eligibility for OAA, ANB, or APTD financial assistance shall be denied.

Source. (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91; ss by #6531, INTERIM, eff 6-27-97, EXPIRES: 10-25-97; ss by #6614, eff 10-24-97; ss by #8452, eff 10-22-05; ss by #10471, eff 11-26-13; ss by #13759, eff 9-28-23