N.H. Code Admin. R. Gcd 303.04 - Application Form

An applicant for participation in TEAP shall provide the following information on the application form:

(a) The applicant's name;

(b) The applicant's residential and e-mail addresses;

(c) The numbers by which the applicant can be reached by telephone, TTYor fax,oremail;

(d) By checking one of 2 boxes labeled "yes" and "no", indicate whether:

(1) The applicant has a disability that makes use of a standard telephone difficult;

(2) The applicant has attached to the application the certification of disability described in Gcd 303.06;

(3) The applicant lives in New Hampshire;

(4) The applicant at the time of application has telephone service or, if not, is able to obtain telephone service;

(5) The applicant receives or is eligible for any of the following programs:

a.Senior companion program;

b.Aid to the needy blind (ANB);

c.Food stamp program;

d.State-funded childcare;

e.Meals on wheels;

f.Elderly nutrition program;

g.Aid to the permanently and totally disabled (APTD);

h.Medical assistance (Medicaid);

i.State fuel assistance;

j.Temporary Assistance to Needy Families (TANF);

k.Headstart;

l.Women, Infants and Children Program (WIC); and

(6) The applicant meets the income eligibility standard for full financial assistance or alternatively the applicant is over the income eligibility limit for full financial assistance and agrees to reimburse the program for 50 per cent of the cost of equipment approved and ordered.

Notes

N.H. Code Admin. R. Gcd 303.04

#7636, eff 1-30-02, EXPIRED: 1-30-10

New. #10128, INTERIM, eff 5-16-12, EXPIRED: 11-13-12

New. #10340, eff 5-17-13