Section He-W 690.01 - Reimbursement(a) Each applicant for OAA or APTD financial assistance, pursuant to RSA 167:28, and each applicant for ANB 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.(b) The agreement required in (a) above shall include: (1) The name of the applicant;(2) The name of the applicant's spouse, if applicable;(3) The applicant's street address;(4) The county where the applicant resides;(5) The physical location where the agreement is being signed;(6) The dated signature of the applicant, and spouse if applicable;(7) The dated signature of a notary public or justice of the peace;(8) The date the commission of the notary public or justice of the peace expires;(9) The raised seal if witnessed by a notary public; and(10) Acknowledgement that the department has advised the applicant of the requirements of RSA 167:16(a) , if applicable.(c) The department shall request applicants for OAA, APTD, ANB, or MEAD medical assistance only and their spouses, if any, to provide their signatures indicating that the department has advised them of the requirements of RSA 167:16(a) , but a signature on the agreement shall not be an eligibility requirement.(d) If an applicant or spouse refuses to complete and sign the agreement, eligibility for OAA, ANB, or APTD financial assistance shall be denied.N.H. Admin. Code § He-W 690.01
(See Revision Note at Chapter Heading He-W 600) #5171, eff 6-26-91; ss by #6531, INTERIM, eff 6-27-97, EXPIRED: 10-25-97; ss by #6614, eff 10-24-97; ss by #8452, eff 10-22-05
The amended version of this section by New Hampshire Register Number 41, eff. 9/28/2023 is not yet available.