NH DSSS 57 2019-2025 free printable template
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State of New Hampshire DEPARTMENT OF SAFETY DIVISION OF STATE POLICEMARINE PATROL 31 DOCK ROAD GILFORD, N.H. 032497627John J. Barthelmes Commissioner of SafetyAPPLICATION FOR WATER EVENT PERMIT (PLEASE
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How to fill out NH DSSS 57
01
Obtain a copy of the NH DSSS 57 form from the New Hampshire Department of Health and Human Services website or your local office.
02
Read the instructions carefully before starting to fill out the form.
03
Fill in your personal information at the top of the form, including your name, address, and contact information.
04
Provide details about your household members, including their names, ages, and relationship to you.
05
Indicate your income sources and the amount received for each member of the household.
06
Complete the section regarding expenses, listing relevant details such as housing costs and medical expenses.
07
Review all the information on the form for accuracy and completeness.
08
Sign and date the form to certify that the information provided is true and correct.
09
Submit the completed form as instructed, either online, by mail, or in person.
Who needs NH DSSS 57?
01
Individuals or families seeking assistance from the New Hampshire Department of Health and Human Services, including those applying for food assistance, cash assistance, or Medicaid.
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What is NH DSSS 57?
NH DSSS 57 is a form used in New Hampshire for reporting certain financial and statistical data related to social services provided by Medicaid.
Who is required to file NH DSSS 57?
Entities that provide services funded by Medicaid and receive reimbursement must file NH DSSS 57 to report their financial information.
How to fill out NH DSSS 57?
To fill out NH DSSS 57, follow the provided instructions, enter the required data accurately, including financial reports, service details, and ensure all sections are completed before submission.
What is the purpose of NH DSSS 57?
The purpose of NH DSSS 57 is to collect comprehensive data for accountability and oversight of social services funded by Medicaid in New Hampshire.
What information must be reported on NH DSSS 57?
Information that must be reported on NH DSSS 57 includes financial expenditures, service delivery data, provider information, and any other relevant details that reflect the operation of Medicaid-funded programs.
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