N.H. Code Admin. R. Ret 502.16 – Filing of NHRS Form FS-1, Financial Affidavit

(a) Every member who files a petition for relief due to a financial inability to pay the member’s assessed share of contributions to purchase enrollment oversight service pursuant to Ret 308.09 shall complete an FS-1 form.
(b) Every member who files an FS-1 form shall provide the following information:
1. (1) The member’s name, Social Security number, address, telephone number, date of birth, age, marital status, and the names of all dependents;
2. (2) The member’s employment status, the employer’s name and address, the spouse’s employment status, and the spousal employer’s name and address;
3. (3) A list of the member’s and spouse’s financial assets including bank accounts, stocks, bonds, trust income and pension plan assets;
4. (4) A breakdown of the member’s and the spouse’s monthly income including wages, alimony, separate maintenance and child support payments;
5. (5) A breakdown of the member’s or family’s monthly housing costs and customary living expenses including rent or mortgage, utilities, food, clothing and miscellaneous expenses;
6. (6) A breakdown of the member’s and spouse’s consumer debts, the names of the creditors, the nature of the purchases, the current balance on each account and the monthly payment for each account;
7. (7) A breakdown of other obligations including alimony, support and child or dependent care and the amounts of the monthly payments;
8. (8) The value of the member’s monthly rent or mortgage payment, the market value of the member’s principal residence, the holder of the mortgage, the balance due, the value of any real estate transfers or sales conducted within 6 months of this application;
9. (9) A description of personal property including automobiles, watercraft, aircraft and recreational vehicles, the value of those items and the balances due on them;
10. (10) A description of other assets not listed elsewhere on this form; and
11. (11) A recitation of any extenuating circumstances which might have a bearing on the determination.
(c) The member shall date, sign and complete the affirmation in the presence of a Justice of the Peace or Notary Public;
(d) Based on the information provided on Form FS-1 and in accordance with the requirements of RSA 100-A:3, VI(d)(3), the review panel shall approve or deny the application, date it and sign it.
Source. #7574, eff 10-10-01, EXPIRED: 10-10-09
New. #9563, eff 10-14-09, EXPIRED: 10-14-17
APPENDIX
Rule
Specific State Statute the Rule Implements
Ret 101 - Ret 102
RSA 100-A:1, RSA 100-A:14, II and RSA 541-A:16, I(a)
Ret 103
RSA 100-A:14, I
Ret 103.01(b) & (c)
RSA 91-A:4, IV
Ret 201 - Ret 204
RSA 100-A:14, II, RSA 541-A:16, I(b)(2) and RSA 541-A:30-a, I
Ret 202.01
RSA 541-A:30-a, III(a)
Ret 205
RSA 541-A:16, I(c)
Ret 206
RSA 541-A:16, I(d)
Ret 301.01 - 301.02
RSA 100-A:1, XI, XXIII; RSA 100-A:3, I(a); and RSA 100-A:7
Ret 302.05
RSA 100-A:14,I; RSA 100-A:3; and RSA 100-A:20
Ret 302.06
RSA 100-A:3,I(a)
Ret 303.01
RSA 100-A:16
Ret 303.02
RSA 100-A:11, II(a)
Ret 304
RSA 100-A:4; and RSA 100-A:16, I and II
Ret 305.01
RSA 100-A:5
Ret 305.02
RSA 100-A:5; RSA 100-A:6; RSA 100:A6, III(c); and RSA 100-A:10
Ret 305.05
RSA 100-A:5; RSA 100-A:6; RSA 100:A6, III(c); and RSA 100-A:10
Ret 305.07
RSA 100-A:6
Ret 305.08
RSA 100-A:19(a)-(h)
Ret 305.09
RSA 100-A:9
Ret 306.01 – 306.02
RSA 100-A:7
Ret 307
RSA 100-A:4
Ret 308
RSA 100-A:3
Ret 309.01
RSA 100-A:16, III
Ret 309.02
RSA 100-A:6 and RSA 100-A:8
Ret 310
RSA 100-A:1, XVII and XVIII
Ret 311.01
RSA 541-A:7
Ret 311.02(a)
RSA 100-A:43-a
Ret 311.02(a)(5)
RSA 100-A:43-b
Ret 311.02(b)-(g)
RSA 100-A:43
Ret 311.03
RSA 100-A:43-b
Ret 311.04
RSA 100-A:43
Ret 312.01(a)-(f)
RSA 100-A:20 and RSA 100-A:29
Ret 312.01(g)-(h)
RSA 100-A:43
Ret 313
RSA 541-A:22, IV
Ret 314
RSA 541-A:22, IV
Ret 400
RSA 100-A:14, I-II, V; RSA 100-A:15, I-V; and Laws of 1990, Chapter 117:3
Ret 501
RSA 541-A:16, I(b)(1)
Ret 502.01
RSA 100-A:3
Ret 502.02
RSA 100-A:5, I
Ret 502.03
RSA 100-A:5, II
Ret 502.04 - 502.05
RSA 100-A:6
Ret 502.06
RSA 100-A:10
Ret 502.07 - 502.12
RSA 100-A:6
Ret 502.13
RSA 100-A:5
Ret 502.14
RSA 100-A:9
Ret 502.15
RSA 100-A:5; RSA 100-A:6; RSA 100-A:10
Ret 502.16
RSA 100-A:3, VI(d)