Jeffrey A. Meyers Commissioner Christine L. Santaniello Director	STATE OF NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF LONG TERM SUPPORTS AND SERVICES BUREAU OF DEVELOPMENTAL SERVICES 105 PLEASANT STREET, CONCORD, NH 03301 603-271-5034 1-800-852-3345 Ext. 5034 Fax: 603-271-5166 TDD Access: 1-800-735-2964 www.dhhs.nh.gov

Laconia State School Trust Fund – Area Agency Request

Name of individual requesting funds:

Was the individual a resident of Laconia State School?

If no, the individual is not eligible for funds

If yes, what time period did the individual reside at Laconia State School?

Reason for Reimbursement Request

Purpose	Amount Requested for Reimbursement	Has individual accessed the fund for this previously? If yes, how much did they access and when?
Yearly Caps Apply (based on SFY)
Transportation ($200/year)	Y N	Amount: Date:
Clothing ($200/year)	Y N	Amount: Date:
Home Equipment and Repair ($1,000/year)	Y N	Amount: Date:
Education ($500/year)	Y N	Amount: Date:
Lifetime Caps Apply
Dental Work ($5,000/lifetime)	Y N	Amount: Date:
Adaptive Durable Medical Equipment ($5,000/lifetime)	Y N	Amount: Date:

Name and address of payee (individual or vendor):

Area Agency Approval

I certify that the above reimbursement request is valid, there are no alternative funds to pay for the request (including Medicaid), this payment will not negatively affect any public benefits received by , and have attached appropriate receipts.

Signature of individual / guardian / representative	Date

Developmental Services Approval

I have reviewed the reimbursement request and supportive documentation and I approve the request and certify that there are no alternative funds to pay for the request (including Medicaid). This payment will not negatively affect any public benefits received by .

Signature of BDS Liaison	Date

Signature of BDS Financial Manager	Date