The New Hampshire IAR Authorization Form, effective April 2002, is provided in Exhibit
NH Department of Health & Human Services Form 151 7/89
SSI Interim Assistance Rev: 3/02
AUTHORIZATION FOR REIMBURSEMENT OF INTERIM ASSISTANCE
Applicant's Name – Please Print Social Security Number
I request that General or Interim Assistance be provided to me during the period in
which my SSI application is pending.
If I am found eligible to receive Supplemental Security Income (SSI) benefits, I understand
that I am authorizing the Commissioner of the Social Security Administration (SSA)
to send to the State of New Hampshire, Department of Health & Human Services (DHHS):
My first retroactive payment of SSI benefits, or
An amount equal to the amount of reimbursable public assistance the Municipality provided
me, if law restricts the manner in which my SSI money can be released to me.
The New Hampshire DHHS may:
Deduct from my first retroactive SSI payment the sum of all Municipality assistance
benefits made to, or on behalf of, me by the Municipality in situations when law does
not restrict the manner in which my SSI money can be released to me, or
Have SSA send an amount equal to the amount of reimbursable public assistance the
Municipality provided to me, if law restricts the manner in which my SSI money can
be released to me,
for the months beginning with:
The first month for which I am eligible to receive an SSI payment,
and ending with, and including:
the month my SSI payment begins, or
the following month if the Municipality cannot promptly stop making its last public
assistance payment to me.
(Assistance financed wholly or in part by federal funds cannot be included.)
I authorize the Municipality to release to the New Hampshire DHHS and/or SSA any records
pertaining to my receipt of Interim Assistance.
The State of New Hampshire, DHHS is required to:
pay me the balance due from the retroactive SSI payment within 10 working days of
the receipt of my SSI payment, and
give me written notice explaining:
How much SSA repaid DHHS for Interim Assistance the Municipality gave to me;
The balance, if any due me, unless the Social Security Act requires SSA to pay me
such balance. (In such an event, SSA will notify me of the manner in which the balance
will be paid to me.); and
That I will have an opportunity for an Administrative Hearing with the DHHS if I disagree
with its actions regarding repayment of Interim Assistance to the Municipality or
any action it took regarding this authorization.
I understand that this authorization is only binding on the Municipality and me if
the Municipality notifies SSA of it within 30 calendar days of the date I signed it.
Also, this form must be signed and dated by both a Municipality representative and
me to be a valid agreement that authorizes the State to receive IAR from my SSI payments.
I understand this authorization is effective for one year from the date the Municipality
receives the signed form from me. However, if I have already applied for SSI before
the Municipality received this authorization, or if I apply for SSI within one calendar
year of the date described above, or I file a timely request for an administrative
review within the time permitted under SSA regulations, this authorization will remain
in effect, even if beyond the one calendar year period, until such time as:
SSA makes the initial SSI payment on my initial claim; or
SSA makes a final determination on my claim; or
The Municipality and I both agree to terminate this authorization.
This form serves as a signed statement of my intention to claim SSI benefits if I
have not filed an SSI application as of the date that this authorization is received
by the Municipality. My eligibility for SSI benefits may begin as early as the date
I sign this form if I file an application at a Social Security office for SSI benefits
within 60 days after that date. This form also serves as a notice from SSA that I
have 60 days from the date the State receives this form to file for SSI benefits.
However, if I do not file an application for SSI benefits at a Social Security office
within 60 days after that date, then I understand that I cancel my intention to claim
SSI benefits and this authorization no longer protects my filing date for SSI.
Applicant's Signature Date
Municipality's Representative's Signature Date