Get NH DFA 768 2017-2024

NH Department of Health and Human Services DHHS Division of Family Assistance DFA DFA Form 768 08/17 SHARED SHELTER ARRANGEMENTS Client Name Physical Address Mailing Case Number Telephone MEAL ARRANGEMENT FOR FOOD STAMPS List everyone who lives with you include all family members and roommates. Relationship to you Is this person s name on the shelter s lease buy his/her own food eat separately from you Yes Person s Signature if over age 18 Date No Yes No SHELTER ARRANGEMENT RENT ROOM BOARD HEAT UTILITIES TELEPHONE ETC. Is your name on the lease for your shelter If yes please complete DFA Form 775 Rental Verification Request or provide a copy of the lease if not on file. My portion of rent is Monthly / Bi-weekly / Weekly circle one I am responsible for a portion of the heating costs separate and apart from my rent and apart from my rent costs separate and apart from my rent Did you receive fuel assistance in the past 12 months If yes please provide copy of approval letter. Client Signature Return to Centralized Scanning Unit CSU P. O. Box 181 Concord NH 03301 DFA SR 17-05 3YC. Relationship to you Is this person s name on the shelter s lease buy his/her own food eat separately from you Yes Person s Signature if over age 18 Date No Yes No SHELTER ARRANGEMENT RENT ROOM BOARD HEAT UTILITIES TELEPHONE ETC. Is your name on the lease for your shelter If yes please complete DFA Form 775 Rental Verification Request or provide a copy of the lease if not on file. Is your name on the lease for your shelter If yes please complete DFA Form 775 Rental Verification Request or provide a copy of the lease if not on file. My portion of rent is Monthly / Bi-weekly / Weekly circle one I am responsible for a portion of the heating costs separate and apart from my rent and apart from my rent costs separate and apart from my rent Did you receive fuel assistance in the past 12 months If yes please provide copy of approval letter. My portion of rent is Monthly / Bi-weekly / Weekly circle one I am responsible for a portion of the heating costs separate and apart from my rent and apart from my rent costs separate and apart from my rent Did you receive fuel assistance in the past 12 months If yes please provide copy of approval letter. Client Signature Return to Centralized Scanning Unit CSU P. O. Box 181 Concord NH 03301 DFA SR 17-05 3YC. Relationship to you Is this person s name on the shelter s lease buy his/her own food eat separately from you Yes Person s Signature if over age 18 Date No Yes No SHELTER ARRANGEMENT RENT ROOM BOARD HEAT UTILITIES TELEPHONE ETC. Is your name on the lease for your shelter If yes please complete DFA Form 775 Rental Verification Request or provide a copy of the lease if not on file. My portion of rent is Monthly / Bi-weekly / Weekly circle one I am responsible for a portion of the heating costs separate and apart from my rent and apart from my rent costs separate and apart from my rent Did you receive fuel assistance in the past 12 months If yes please provide copy of approval letter. .