Current through Register No. 12, March 21, 2024
(a) Every
member who files a petition for relief due to a financial inability to pay the
member's assessed share of contributions to purchase enrollment oversight
service pursuant to Ret 308.09 shall complete an
FS-1 form.
(b) Every member who
files an FS-1 form shall provide the following information:
(1) The member's name, Social Security
number, address, telephone number, date of birth, age, marital status, and the
names of all dependents;
(2) The
member's employment status, the employer's name and address, the spouse's
employment status, and the spousal employer's name and address;
(3) A list of the member's and spouse's
financial assets including bank accounts, stocks, bonds, trust income and
pension plan assets;
(4) A
breakdown of the member's and the spouse's monthly income including wages,
alimony, separate maintenance and child support payments;
(5) A breakdown of the member's or family's
monthly housing costs and customary living expenses including rent or mortgage,
utilities, food, clothing and miscellaneous expenses;
(6) A breakdown of the member's and spouse's
consumer debts, the names of the creditors, the nature of the purchases, the
current balance on each account and the monthly payment for each
account;
(7) A breakdown of other
obligations including alimony, support and child or dependent care and the
amounts of the monthly payments;
(8) The value of the member's monthly rent or
mortgage payment, the market value of the member's principal residence, the
holder of the mortgage, the balance due, the value of any real estate transfers
or sales conducted within 6 months of this application;
(9) A description of personal property
including automobiles, watercraft, aircraft and recreational vehicles, the
value of those items and the balances due on them;
(10) A description of other assets not listed
elsewhere on this form; and
(11) A
recitation of any extenuating circumstances which might have a bearing on the
determination.
(c) The
member shall date, sign and complete the affirmation in the presence of a
Justice of the Peace or Notary Public;
(d) Based on the information provided on Form
FS-1 and in accordance with the requirements of
RSA
100-A:3, VI(d)(3), the review panel shall
approve or deny the application, date it and sign it.
