Page 1 of 17
NJFC-ABD-APAUSP-1222
FOR OFFICE USE ONLY
HMO choice _____________________________________________
Date Applied ____________________________________________
Case # __________________________________________________
STATE OF NEW JERSEY
Department of Human Services
Division of Medical Assistance and Health Services
NJ FamilyCare
Aged, Blind, Disabled Programs
SECTION 1
Applicant
Applicant’s Name: _________________________ ____________________ _____________ __________________
Last First Middle Maiden Name
Home Address: ____________________________________ _______________________ ______ _____________
Street City State Zip Code
Current Mailing Address (if different from above):
_____________________________________________________ _______________________ ______ _____________
Street City State Zip Code
Is Applicant living in a nursing facility? q Yes q No
If Applicant has not lived at the Home Address for 5 years, tell us the previous address:
(Attach additional information if needed)
_____________________________________________________ _______________________ ______ _____________
Street City State Zip Code
Applicant’s Phone Number: (
_____ _____ _____ ) _____ _____ _____ - _____ _____ _____ _____
Applicant’s E-mail Address: _______________________________________________________________________
Is the Applicant Blind or Disabled? q Yes If yes, as of what date: _______________________ q No
Has the Applicant applied for Supplemental Security Income (SSI)?
q Yes If yes, when ____ ____ – ____ ____ ____ ____ q No
Month Year
Does the Applicant have a history of a severe or chronic intellectual disability or developmental
disability that occurred before age 22 and is indicated by intellectual disability, autism,
cerebral palsy, epilepsy, spina bifida or other neurological impairments? q Yes q No
Does the Applicant need “nursing home like” services, Long Term Services and
Supports, such as dressing, bathing or mobility assistance? See Brochure. q Yes q No
Has the Applicant ever applied before? q Yes If yes, which county _______________________ q No
Date of Birth: ____ ____ – ____ ____ – ____ ____ ____ ____ Sex: q Male q Female
Month Day Year
Citizenship Status: 
  q US citizen or US national  q Naturalized or derived citizen (born outside of the US)
If naturalized or derived citizen, enter
USCIS #___________________________________ and Certificate #__________________________________
Certificate Type: q Naturalization Certificate q Certificate of Citizenship
APPLICATION
SECTION 2
Demographic Information for the Applicant
Page 2 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
Spouse’s Name: _________________________ ____________________ ____________ ______________________
Last
First Middle Maiden Name
Spouse’s Date of Birth:
____ ____
–
____ ____ – ____ ____ ____ ____
Month Day Year
Spouse’s Social Security Number: ____ ____ ____
– ____ ____
–____ ____ ____ ____
Spouse’s
Address (last known)
_____________________________ _____________________ ______ ________
Street City State Zip Code
Is this person also applying for the Aged, Blind, Disabled Programs?
q No q Yes, please complete the Spouse Information form.
SECTION 3
Spouse’s Name
If not a citizen, does the Applicant have an eligible immigration status?
Examples of eligible immigration status are:   
  • Child under age 21 or pregnant woman: Lawfully residing in the US
  • Adult: Lawful Permanent Resident for 5 years OR qualified non-citizen, such as refugee or asylee
q Yes, enter information below: q No
  Immigration document type_________________________ Status type (optional)_____________________
  Applicant’s name as it appears on immigration document______________________________________
  USCIS or I-94 number________________________ Card or Passport Number_______________________
  SEVIS ID or expiration date (optional) ________________________________________
  Other (category code or country of origin) ___________________________________________________
  Has the Applicant lived in the US since 1996? q Yes q No
  Is the Applicant, or Applicant’s spouse or parent, a veteran or an active-duty member
of the US military? q Yes q No
Social Security Number (SSN): ____ ____ ____ – ____ ____ –____ ____ ____ ____
If no SSN, has the Applicant applied for one?
q Yes q No Enter reason: q Not needed for work q Religious reasons q Not eligible
If you have an SSN, providing your SSN and the SSN of other household members can speed up the applica-
tion process. We use SSNs to check income and other information to see who in your household qualifies
for health coverage. If someone wants help getting an SSN, call 1-800-772-1213 (TTY: 1-800-325-0778) or visit
socialsecurity.gov. If you do not have an SSN, we will use other documents to process your application.
Medicare ID Number: ____________________________________________________
Marital Status: q Single   q Married, Date _________________   q Divorced, Date ________________
q Widowed, Spouse’s Date of Death _______ q Child (under age 19) q Separated, Date ________
Your answers to questions about race and ethnicity can help us serve the community better. They will not
affect if you qualify for coverage or what services you can receive.
Race (Check all that apply.) q Prefer not to answer
q White q Asian Indian q Korean q
Guamanian or Chamorro
q American Indian q Chinese q Vietnamese q Native Hawaiian
or Alaska Native q Filipino q Other Asian: q Samoan
q Black or African American q Japanese _______________ q Other Pacific Islander:
q Other:____________________ _________________________
Ethnicity (Check all that apply) q Prefer not to answer
q Mexican, Mexican American, q Puerto Rican q
Another Hispanic, Latino/a, or Spanish origin
Chicano/a q Cuban q Not of Hispanic, Latino/a, or Spanish origin
Also include if divorced, separated or widowed.
SECTION 2 - DEMOGRAPHIC INFORMATION FOR THE APPLICANT - continued
Page 3 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
SECTION 5
Health Insurance Information
q Medicare Part A Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
q Medicare Part B Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
q Medicare Part C Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
q Medicare Part D Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
Does the Applicant have any other health insurance coverage? q Yes q No
If yes, list below the name of the health coverage, policy number, and any premium costs.
Does the Applicant have Long Term Care Insurance? q Yes q No
Does the Applicant have a New Jersey Department of Banking
and Insurance approved Long Term Care Partnership Policy? q Yes q No
If the Applicant answered yes to either of these questions, please provide a copy of the policy(s).
Name of Policy Policy Number Policy Premium
SECTION 4
Assistance with Application
The applicant can choose someone to help them complete their application. We can
contact this person for more information. Select Below:
q Authorized Representative
- Complete the Designation of Authorized Representative Form
(included).
q
Power of Attorney
q
Legal Guardian
q
Attorney
q
Spouse
q
Other, please identify relationship ________________________________________________________
Provide the following information for this person:
Name
__________________________________________________________________________________________
Address
____________________________________________ _______________________ ______ _____________
Street City State Zip Code
Phone Number: __ __ __ __ __ __ __ __ __ __ E-mail Address: _____________________________________
(
)
–
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NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
Applicant’s current living arrangement, check all that apply.
  q Home: Own q Rent q q Living with Spouse q Nursing Facility
  q Assisted Living Facility q Residential Care Facility
  q Renting a room(s) in another person's residence q Living with Relative or Friend
q Other: Living Arrangement: ___________________________________________________________________
List other people living with the Applicant; include name, date of birth, and relationship
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SECTION 6
Living Arrangements
SECTION 7
Income Information
This section talks about the income that the Applicant receives. Income is any cash or in kind
support that can be used for food or shelter.
Income can be wages, tips, and commissions. Income can also be government benefits (such as
Social Security Benefit), interest or dividends.
q I do not have any income. If not, how do you pay your bills? _________________________________
__________________________________________________________________________________________________
Current Job & Income Information
q
Employed
If Applicant is
currently
employed,
tell
us
about Applicant’s income.
Start with
question
1.
q Self-
employed
Skip to question
10.
q
Not employed
Skip to question
11.
CURRENT JOB
1:
1. Employer name and address _________________________________________________________________
_____________________________________________________ _______________________ ______ __________
2. Employer phone
number
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____
3. Work Income (before taxes)
q Hourly
q Weekly
q Every 2 weeks
q Twice a month
q Monthly
q Yearly
$
__________________________________
4. Average hours worked each WEEK __________________________________
(
)
–
Does the Applicant have any income from employment? q Yes q No
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NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
CURRENT JOB
2:
(If the Applicant has more jobs and needs more space, attach another sheet of
paper.)
5. Employer name and address _________________________________________________________________
________________________________________________________________________________________________
6. Employer phone
number
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____
7. Work Income (before taxes)
q Hourly
q Weekly
q Every 2 weeks
q Twice a month
q Monthly
q Yearly
$
__________________________________
8. Average hours worked each WEEK __________________________________
9. In the past year, did the Applicant: q Change jobs q Stop working
q Start working fewer hours q None of
these
10. If self-employed, answer the following
questions:
a. Type of work _______________________________________________________________________________
b. How much net income (profits once business expenses
are
paid) will the Applicant
get from this
self-employment
this
month? $__________________________________________
11.
OTHER
INCOME:
Check all that apply, and give the amount and how often does the Applicant get
it.
q None
q Unemployment $______________________ How often? _________________________________
q Pensions $______________________ How often? _________________________________
q Social Security $______________________ How often? _________________________________
q Retirement accounts $______________________ How often? _________________________________
q Alimony received $______________________ How often? _________________________________
q Child Support $______________________ How often? _________________________________
q Work Compensation/
Disability $______________________ How often? _________________________________
q Cash Support $______________________ How often? __________ From who?___________
q Net rental/royalty $______________________ How often? _________________________________
q Annuity $______________________ How often? _________________________________
q Other income $______________________ How often? _________________________________
12.
YEARLY
INCOME
:
Complete only if your income changes from month to month.
If you don’t expect changes to your monthly income, skip to the next page.
Your total income this year $ _____________________
Your total income next year (if you think it will be different) $ ___________________________
(
)
–
CURRENT JOB
2:
(If the Spouse has more jobs and needs more space, attach another sheet of
paper.)
17. Employer name and address _________________________________________________________________
________________________________________________________________________________________________
18. Employer phone
number
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____
19. Work Income (before taxes)
q Hourly
q Weekly
q Every 2 weeks
q Twice a month
q Monthly
q Yearly
$
__________________________________
20. Average hours worked each WEEK __________________________________
21. In the past year, did the Spouse: q Change jobs q Stop working
q Start working fewer hours q None of
these
22. If Spouse is self-employed, answer the following
questions:
a. Type of work _______________________________________________________________________________
b. How much net income (profits once business expenses
are
paid)
will the Spouse get from this
self-employment
this
month? $_________________________
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NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
Please complete the following section with all information on Spouse’s income
SECTION 7a
Spouse’s Income
Current Job & Income Information
q
Employed
If Spouse is
currently
employed,
tell
us
about Spouse’s income.
Start with
question
13.
q Self-
employed
Skip to question
22.
q
Not employed
Skip to question
23.
CURRENT JOB
1:
13. Employer name and address _________________________________________________________________
________________________________________________________________________________________________
14. Employer phone
number
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____
15. Work Income (before taxes)
q Hourly
q Weekly
q Every 2 weeks
q Twice a month
q Monthly
q Yearly
$
__________________________________
16. Average hours worked each WEEK __________________________________
( ) –
( ) –
Page 7 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
23.
OTHER
INCOME:
Check all that apply, and give the amount and how often does the Spouse get
it.
q None
q Unemployment $______________________ How often? _________________________________
q Pensions $______________________ How often? _________________________________
q Social Security $______________________ How often? _________________________________
q Retirement accounts $______________________ How often? _________________________________
q Alimony received $______________________ How often? _________________________________
q Child Support $______________________ How often? _________________________________
q Work Compensation/
Disability $______________________ How often? _________________________________
q Cash Support $______________________ How often? __________ From who?___________
q Net rental/royalty $______________________ How often? _________________________________
q Annuity $______________________ How often? _________________________________
q Other income $______________________ How often? _________________________________
24.
YEARLY
INCOME
:
Complete only if your income changes from month to month.
If you don’t expect changes to your Spouse’s income, skip to the next page.
      Spouse’s total income this year $ _____________________
      Spouse’s total income next year (if you think it will be different) $ _____________________
Page 8 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
SECTION 8
Resources for Applicant and Applicant’s Spouse
Please detail all resources owned in full or in part by the Applicant, and/or the Applicant’s
Spouse.
q
Cash on hand $
___________________________
ACCOUNTS: This includes but is not limited to, checking, savings, business checking accounts,
ABLE Accounts, Certificates of Deposit (CD), Holiday/Vacation club accounts, Credit Union
accounts, Burial Accounts/Funeral Trusts owned or closed by the Applicant and/or Applicant’s
Spouse within 60 months of application date.
Account Type ____________________________________________________________________________________
Bank Name and Address ____________________________________________________________________________
Name(s) on Account ______________________________________________________________________________
Account or Certificate # _________________________________________ Current Value ___________________
If Closed, Date Closed & Value ____________________________________________________________________
Account Type ____________________________________________________________________________________
Bank Name and Address ____________________________________________________________________________
Name(s) on Account ______________________________________________________________________________
Account or Certificate # _________________________________________ Current Value ___________________
If Closed, Date Closed & Value ____________________________________________________________________
Account Type ____________________________________________________________________________________
Bank Name and Address ____________________________________________________________________________
Name(s) on Account ______________________________________________________________________________
Account or Certificate # _________________________________________ Current Value ___________________
If Closed, Date Closed & Value ____________________________________________________________________
Account Type ____________________________________________________________________________________
Bank Name and Address ____________________________________________________________________________
Name(s) on Account ______________________________________________________________________________
Account or Certificate # _________________________________________ Current Value ___________________
If Closed, Date Closed & Value ____________________________________________________________________
Type of Real Estate _____________________________________________________________________________
Address __________________________________________________________________________________________
Liens, Mortgages or Incumbrances _____________________________ Fair Market Value______________
Owners __________________________________________________________ If Sold, Date __________________
Type of Real Estate _____________________________________________________________________________
Address __________________________________________________________________________________________
Liens, Mortgages or Incumbrances _____________________________ Fair Market Value______________
Owners __________________________________________________________ If Sold, Date __________________
Type of Real Estate _____________________________________________________________________________
Address __________________________________________________________________________________________
Liens, Mortgages or Incumbrances _____________________________ Fair Market Value______________
Owners __________________________________________________________ If Sold, Date __________________
Page 9 of 17
Type of Investment _______________________________________________________________________________
Company ________________________________________________________________________________________
Account # ______________________________________________ Current Value ___________________________
If Closed, Date Closed & Value ____________________________________________________________________
Type of Investment _______________________________________________________________________________
Company ________________________________________________________________________________________
Account # ______________________________________________ Current Value ___________________________
If Closed, Date Closed & Value ____________________________________________________________________
Type of Investment _______________________________________________________________________________
Company ________________________________________________________________________________________
Account # ______________________________________________ Current Value ___________________________
If Closed, Date Closed & Value ____________________________________________________________________
INVESTMENTS:
Including but not limited to: Individual Retirement Accounts (IRAs), Keogh
Accounts (401K), Retirement Plans (403B), Land/Mineral Rights,
Business Equipment and
Inventory, Promissory Notes and Contracts,
Stocks, Bonds owned or traded/closed by the
Applicant and/or Applicant’s Spouse within 60 months of application date.
PROPERTY: Properties owned solely by the Applicant, with the Applicant’s Spouse and/or
with others (including but not limited to Other Homes, Land, Buildings, Time Shares,
Life Estates or sold within the last 60 months).
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
No Investments q
No Property q
Page 10 of 17
Owner__________________________________________________________________________________________
Year/Make _______________________________________ Model/Style _____________________________________
Primary Use ____________________________________________ Amount Owed ________________________
Owner__________________________________________________________________________________________
Year/Make _______________________________________ Model/Style _____________________________________
Primary Use ____________________________________________ Amount Owed ________________________
Owner__________________________________________________________________________________________
Year/Make _______________________________________ Model/Style _____________________________________
Primary Use ____________________________________________ Amount Owed ________________________
Owner __________________________________________________________________________________________
Insured _________________________________________________________________________________________
Insurance Company ____________________________________________________________________________
Policy # ______________________ Face Value _______ Cash Value _______ Term or Whole Life _______
Owner __________________________________________________________________________________________
Insured _________________________________________________________________________________________
Insurance Company ____________________________________________________________________________
Policy # ______________________ Face Value _______ Cash Value _______ Term or Whole Life _______
Owner __________________________________________________________________________________________
Insured _________________________________________________________________________________________
Insurance Company ____________________________________________________________________________
Policy # ______________________ Face Value _______ Cash Value _______ Term or Whole Life _______
LIFE INSURANCE POLICIES
List all life insurance policies owned by the Applicant and/or Applicant’s Spouse or for which
the Applicant(s) are named insured.
VEHICLES: List all vehicles owned by the Applicant and/or Applicant’s Spouse, applying
for benefits.
List all types of vehicles, including but not limited to, cars, vans, trucks,
motor homes, motorcycles, boats, etc.
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
No Life Insurance q
No Vehicles q
Does the Applicant and/or Applicant’s Spouse have any knowledge of
being named a beneficiary on someone else’s policy?
q Yes q No
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NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
TRUSTS
Testamentory Trust q Special Needs Trust q Qualified Income Trust q
Grantor ___________________________________________________________________________________________
Trustee ____________________________________________________________________________________________
Beneficiary ________________________________________________________________________________________
Trust was funded by q Applicant q Inheritance q Will q Lawsuit q Other
Tax ID# _______________________________________ Date trust was initially funded ____________________
Burial Arrangements
Does the Applicant own any prepaid burial contracts that are irrevocable or revocable?
   q Yes If yes, please send contract. q No
q Burial plots
q Account set aside for burial Account #______________________________ Value ________________
Identified Funeral Home (name and address) _____________________________________________________
Has the Applicant or anyone else set up a burial arrangement or contract through
a life insurance policy? q Yes If yes, please send policy. q No
OTHER RESOURCES NOT LISTED ___________________________________________________________
SECTION 9
Transfers
Did the
Applicant and/or Applicant’s Spouse trade, give away, or sell resources in which the
Applicant and/or Applicant’s Spouse had an interest within the last 60 months, including
but not limited to cash, real estate, vehicles, businesses, stocks, bank accounts?
q Yes
If yes, complete the information below for each transfer.
q
No
Item Transferred______________________________________________Transfer Date____________________
Market Value __________________________________ Amount Received ________________________________
Item Transferred______________________________________________Transfer Date____________________
Market Value __________________________________ Amount Received ________________________________
Item Transferred______________________________________________Transfer Date____________________
Market Value __________________________________ Amount Received ________________________________
Has the Applicant established a Plan of Liquidation for any
of the resources in Section 8? q Yes q No
Page 12 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
SECTION 10
Legal Issues
Has the Applicant received medical services within the past 3 months?
   q Yes q
No
Are there any pending claims such as lawsuits, divorce settlements, inheritance, accident claims,
Medical Malpractice or other claims? q Yes q No
If Yes, provide details of the claims including but not limited to date monies were received and
type of claim
.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Attorney’s Name __________________________________________________________________________________
Attorney’s Phone Number _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Attorney’s Address ________________________________________________________________________________
Will the Applicant and/or Applicant’s Spouse file a lawsuit in the future? q Yes q No
Does anyone owe the Applicant and/or the Applicant’s Spouse money,
for example loans, promissory notes and/or mortgages? q Yes q No
If yes, provide details regarding these arrangements. _____________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(
)
–
Choose a Health Plan from the list below. If the Applicant does not choose now, the Applicant will
have an opportunity to select a Health Plan before enrollment occurs. The Applicant must be
enrolled in a Health Plan to receive all of the services offered through NJ FamilyCare. The Health
Plan selected only applies if the Applicant(s) is eligible for NJ FamilyCare. If the Applicant(s) needs
assistance selecting the Applicant(s) Health Plan, contact a Health Benefits Coordinator at
1-800-701-0710, TTY: 711.
I understand that if I’m found eligible and because I have joined a Health Plan, I must follow the
rules for obtaining health care from the Health Plan. I understand that I must let my Health Plan
and NJ FamilyCare know if there is any change in the number of people in my family and that any
newborn children will be enrolled in my Health Plan. I understand that, unless I, or a family
member, have a true medical emergency, I must call my personal doctor for medical advice,
medical care or for a referral to a specialist. I understand that if I, or a family member, have a
true medical emergency, I must call my personal doctor or the Health Plan as soon as possible
after I, or the family member, go to the hospital. I understand that I must keep any medical
appointment I have scheduled with a doctor and, if I cannot, I must call the doctor’s office to
cancel the appointment. I understand that if I go to a doctor other than my personal doctor I
have selected, without a referral from my doctor or approval from the Health Plan, I may have to
pay for that doctor’s services because NJ FamilyCare will not pay for the unapproved service or
visit. I understand that I may change to another Health Plan and that I can call the Health
Benefits Coordinator to help me do that. I give permission for the release of my medical history
and health care records and those of my family members who will be enrolled to any person(s)
in the Health Plan and its providers who shall provide or coordinate health care to me and my
family as long as I am a member of the Health Plan.
In certain counties, eligible participants age 55 and over who reside in the community needing
Long Term Services and Supports may instead have their care provided through PACE (Program
of All-Inclusive Care for the Elderly). Call 1-800-792-8820 for more information about PACE in
your community.
Page 13 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
SECTION 11
Select the Applicant’s Health Plan
Choose One:
q Aetna Better Health
®
of New Jersey (Available in ALL counties)
q Amerigroup New Jersey, Inc. (Available in ALL counties)
q Horizon NJ Health (Available in ALL counties)
q UnitedHealthcare Community Plan (Available in ALL counties)
q WellCare Health Plans of New Jersey
(Available in ALL counties, except Hunterdon county)
+
Page 14 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
SECTION 12
Applicant and Beneficiary Rights and Responsibilities
Before signing this document, please read the rights and responsibilities outlined below. If there
is anything you do not understand or have questions about, please ask for clarification.
• If I am a third party applying on behalf of another person, as evidenced by a completed
Designation of Authorized Representative Form, my signature below indicates that this
application has been examined by, or read to, the applicant and, to the best of my knowledge,
the facts are true and complete. I understand that as a third party, I may be criminally
punished for knowingly providing false information.
• I understand that any information I give is subject to verification by the New Jersey Depart-
ment of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS)
for the Medicaid/NJ FamilyCare program, which is called “NJ FamilyCare” in this application.
I understand that my medical benefits may be reduced, denied, or stopped because of
information received through this verification.
• I understand that my situation is subject to verification from employers, financial sources, and
other third parties. I hereby give permission to NJ FamilyCare to contact any individual or
other source that may have knowledge about my circumstances, or the circumstances of a
person necessary for this application, for the purpose of verifying the statements I have
made. I give third parties permission to share information about me with authorized State,
State contractor, and county staff conducting investigations. Third parties include, but are not
limited to, financial institutions, credit reporting agencies, landlords, public housing agencies,
schools, utility companies, insurance agencies, employers, other governmental agencies, and
others, as necessary. I further authorize taxing authorities to release my tax information and
copies of my tax returns.
• I understand that DHS, including its operating Divisions, eligibility determining agencies,
government contractors, and other appropriate State of New Jersey agencies, may exchange
information relating to coverage to assist with this application, enrollment, administration, and
billing services.
• I understand that DMAHS has the authority to file a claim and lien against the estate of a
deceased Medicaid beneficiary, or former beneficiary, to recover all NJ FamilyCare payments
made on the beneficiary’s behalf to pay for health care coverage on or after age 55, regardless
of whether services were received. An NJ FamilyCare beneficiary’s estate may be required to
pay back DMAHS for those benefits. This includes monthly payments to, for example, a
managed care entity to secure health care coverage that you may not use in any month.
More information about Estate Recovery is available online at:
www.state.nj.us/humanservices/dmahs/clients/The_NJ_Medicaid_Program_and_Estate_
Recovery_What_You_Should_Know.pdf
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NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
• I agree to tell the eligibility determining agency immediately of changes to information
entered on this application including, but not limited to, the following:
1) If anyone receiving health benefits moves out of New Jersey;
2) Changes in where we live, get our mail, or any other contact information;
3) Changes in other health insurance coverage;
4) Changes in income and/or resources;
5) Improvement in medical condition, if disabled;
6) Marriage, divorce, or death of a spouse;
7) Addition or loss of household member, including pregnancy;
8) Sale or transfer of my home or other property; or,
9) Lawsuits and inheritances.
I understand that failure to report changes in application information, including those changes
listed above, may result in incorrectly paid benefits/coverage, and I may have to reimburse the
State of New Jersey for those benefits/coverage.
• I understand that the outcome of this application may be shared with any provider who
provided services to the applicant/beneficiary during the period covered by the application.
• I understand, as a condition of being covered under Medicaid/NJ FamilyCare, that I have
assigned to the Commissioner of the Department of Human Services any rights to support
for the purpose of medical care as determined by a court or administrative order and any
rights to payment for medical care from a third party including, but not limited to, other
health insurance, legal settlements, or other third parties. I agree to release any medical
information needed by the NJ FamilyCare program, or others, for the purpose of paying or
receiving payment of medical bills. I agree to help in obtaining medical support and
payments from anyone who is legally responsible.
• I understand that I may request a fair hearing if I am not satisfied with the determination of
my application.
• I may be eligible for retroactive NJ FamilyCare coverage for unpaid, covered medical services
by Medicaid Fee-for-Service providers during the three (3) months prior to this application.
I further understand that these retroactive benefits will only apply to the month(s) that
eligibility requirements are met.
• I understand that an individual is only permitted to retain a certain amount in resources,
depending on the program’s eligibility requirements. I understand that if I am seeking Long
Term Services and Supports or services based on an institutional level of care, NJ FamilyCare
will examine transfers of resources that occurred within the 5 year look-back period before,
SECTION 12 - APPLICANT AND BENEFICIARY RIGHTS AND RESPONSIBILITIES - continued
Page 16 of 17
NJFC-ABD-APAUSP-1222
Application for Aged, Blind and Disabled Programs
and any time after, my first date of applying for benefits.
• In order to redetermine my eligibility for NJ FamilyCare in the future, I agree to allow
NJ FamilyCare to use income data, including tax information. At time of renewal, NJ FamilyCare
will send me a renewal notice and let me indicate any changes in my or my household’s
eligibility information, and I can withdraw my request for benefits in writing at any time.
• I understand that if some or all of the individuals applying do not qualify for NJ FamilyCare
health care coverage, that they may be eligible for federal benefits and/or may explore private
health care coverage options through the State of New Jersey’s Health Insurance Marketplace
(Marketplace) at GetCovered.NJ.gov.
If this is the case, I authorize NJ FamilyCare and its contractors to give information contained in
this application to the Marketplace.
• I confirm that I have read and understood the NJ FamilyCare Privacy Policy available online at:
https://njfc.force.com/familycare/NJPrivacyNotice and the Notice of Privacy Practices available
online at: www.njfamilycare.org/docs/NJFC-HIPAA.pdf
• I understand that NJ FamilyCare may use or disclose protected health information about me
or my children if State or federal privacy laws require or allow it.
• I authorize my employer to release health benefits information to the NJ FamilyCare Office of
Premium Support.
• I will obey the law and regulations of NJ FamilyCare.
• I know that under federal law, discrimination is not permitted on the basis of race, color,
national origin, sex, age, or disability. I can get more information, including how to file a
complaint of discrimination, by reading the NJ FamilyCare Non-Discrimination Statement
available online at: www.njfamilycare.org/docs/ndc_english.pdf
NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with
42 U.S.C. 1320b-7. The SSNs provided (including for a husband or wife, family members, or
dependents) will be used to associate records pertaining to applicants and other persons
necessary for the determination of eligibility, to verify identity, to verify income, and to
check other financial records, such as bank account information, to the extent it is useful
in verifying eligibility or the amount of medical assistance payments under 42 CFR 435.940
through 435.960 and to prevent duplicate participation or incorrectly paid benefits for you
and for persons in your household. The SSNs will be used in computer matching and
program reviews or audits. These procedures are designed to determine eligibility and to
identify persons who fraudulently or wrongfully participate in Medicaid and DHS programs.
Such persons may be subjected to criminal action, administrative claims, and/or possible
loss of all benefits. Failure to file for a SSN may result in disqualification for Medicaid.
SECTION 12 - APPLICANT AND BENEFICIARY RIGHTS AND RESPONSIBILITIES - continued
Application for Aged, Blind and Disabled Programs
Page 17 of 17
NJFC-ABD-APAUSP-1222
NJ FamilyCare complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, sex, age or disability. If you speak any other language,
language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 711).
SECTION 13
Applicant Signature
_________________________________________________________________________
_______________________
Applicant’s Signature Date (mm/dd/yyyy)
________________________________________________________________________________________
_____________________________
Authorized Representative Name Relationship
________________________________________________________________________________________
_____________________________
Authorized Representative Signature Date (mm/dd/yyyy)
This application cannot be considered until it is received by the Eligibility Determining Agency.
The person who filled out this application must sign this application. If you’re an authorized
representative, you may sign here, as long as you have provided the Designation of Authorized
Representative Form.
By signing below, I certify under penalty of perjury and false swearing that my answers on this
application are true, correct, and complete to the best of my knowledge. I also certify that:
• I understand the questions and statements on this application.
• I understand that I may be subject to penalties under federal and State law if I provide false
or untrue information.
By signing below I also certify that I have read and understand the Applicant and Beneficiary
Rights and Responsibilities included.
Intentionally left blank
ATLANTIC COUNTY DIVISION OF INTERGENERATIONAL
609-645-7700
BERGEN COUNTY BOARD OF SOCIAL SERVICES
201-368-4200
MONMOUTH COUNTY DIVISION OF SOCIAL SERVICES
732-431-6000
BURLINGTON COUNTY BOARD OF SOCIAL SERVICES
609-261-1000
CAMDEN COUNTY BOARD OF SOCIAL SERVICES
856-225-8800
CAPE MAY COUNTY BOARD OF SOCIAL SERVICES
609-886-6200
CUMBERLAND COUNTY BOARD OF SOCIAL SERVICES
856-691-4600
SALEM COUNTY BOARD OF SOCIAL SERVICES
856-299-7200
973-733-3000
GLOUCESTER COUNTY DIVISION OF SOCIAL SERVICES
856-582-9200
SUSSEX COUNTY DIVISION OF SOCIAL SERVICES
973-383-3600
HUDSON COUNTY DEPARTMENT OF FAMILY SERVICES
201-420-3000
HUNTERDON COUNTY DEPT OF HUMAN SERVICES
908-788-1300
WARREN COUNTY DIVISION OF TEMPORARY
908-475-6301
MERCER COUNTY BOARD OF SOCIAL SERVICES
609-989-4320
SIGN Application and SEND to your
LOCAL COUNTY WELFARE AGENCY
at the appropriate address listed below.
NEW JERSEY COUNTY WELFARE AGENCIES
SUPPLEMENTAL INFORMATION
Designation of
Authorized Representative Form
DESIGNATION OF AUTHORIZED REPRESENTATIVE FORM
I, _________________________________________ hereby authorize the following person or company to be
(Name of Applicant)
my Authorized Representative in my application for Medicaid filed with the Eligibility Determining
Agency (EDA) or New Jersey Division of Medical Assistance and Health Services (DMAHS) and in all
review of my eligibility. I authorize my representative to take any action which may be necessary
to establish my eligibility for NJ FamilyCare.
My decision to appoint an Authorized Representative is voluntary and made freely. I
understand that signing this document does not relieve me of my responsibility to
participate in the NJ FamilyCare eligibility process, including providing information
and documents.
I understand that as a result of this authorization, the DMAHS and the applicable
EDA may disclose and release information to the Authorized Representative including
my Social Security number, financial statements, medical information and the reasons
for denial.
I have been fully informed in writing by the Authorized Representative of actual or
potential conflicts of interest that may exist between the above named entity and me.
I hereby waive any conflict of interest. If there is no conflict of interest, the
Authorized Representative has also put that in writing.
I understand that the information shared with the Authorized Representative may
affect my liability to a third party, include the Authorized Representative and may be
disclosed to others. I hereby hold DMAHS and the EDA harmless for any claim or
action resulting from the use or disclosure of information by my Authorized Repre-
sentative.
_________
initial
_________
initial
_________
initial
_________
initial
Name of Representative: ____________________________________________________________________________
Company: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
City, State, Zip: ______________________________________________________________________________________
Phone Number: _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
STATE OF NEW JERSEY
Department of Human Services
Division of Medical Assistance and Health Services
(
)
–
-
SIGN ON BACK
+
NJFC-ABD-APAUSP-1222
Page 1 of 2
____________________________________________________________ _____________________________
Signature of NJ FamilyCare Applicant Date (mm/dd/yyyy)
or Person Granting Authority
____________________________________________________________
Relationship (Self, Guardian, etc.)
____________________________________________________________ _____________________________
Witness Date (mm/dd/yyyy)
____________________________________________________________
Print Name
____________________________________________________________ ___________________________________________
Signature of Authorized Representative Title (if employee of authorized company)
____________________________________________________________ ______________________________
Print Name Date (mm/dd/yyyy)
____________________________________________________________ ______________________________
Witness Date (mm/dd/yyyy)
____________________________________________________________
Print Name
Signatures
Designation of Authorized Representative Form
This form has no effect unless witnessed and signed by the person granting authority
and by the Authorized Representative or an agent of the company
appointed to be the Authorized Representative.
I understand that I may revoke this authorization at any time by notifying the Authorized
Representative and the EDA in writing.
I understand that while this authorization is in effect, all notices/correspondence sent
by DMAHS and the applicable EDA will only be sent to the Authorized Representative.
I understand that neither the State of New Jersey nor the EDA charge a fee to file a
NJ FamilyCare application.
_________
initial
_________
initial
_________
initial
NJFC-ABD-APAUSP-1222
Page 2 of 2
SUPPLEMENTAL INFORMATION
Spouse Information Form
Intentionally left blank
Page 1 of 7
NJFC-ABD-APAUSP-1222
SECTION 1
Applicant 2 (Spouse)
Applicant 1 Name:
____________________________________ _______________________ _____________ _______________________
Last First Middle Date of Birth (mm/dd/yyy)
Applicant 2 (Spouse) Name:
____________________________________ _______________________ _____________ _______________________
Last First Middle Maiden Name
If Applicant has not lived at the Home Address for 5 years, tell us the previous address:
(Attach additional information if needed)
_____________________________________________________ _______________________ ______ _____________
Street City State Zip Code
Current Mailing Address (if different from above).
_____________________________________________________ _______________________ ______ _____________
Street City State Zip Code
Applicant’s Applicant’s
Phone Number: __ __ __ __ __ __ __ __ __ __ E-mail Address: _____________________________________
Is the Applicant Blind or Disabled? q Yes If yes, as of what date: _______________________ q No
Has the Applicant applied for Supplemental Security Income (SSI)?
q Yes If yes, when ____ ____ – ____ ____ ____ ____ q No
Month Year
Does the Applicant have a history of a severe or chronic intellectual disability or developmental
disability that occurred before age 22 and is indicated by intellectual disability, autism, cerebral
palsy, epilepsy, spina bifida or other neurological impairments? q Yes q No
Does the Applicant need “nursing home like” services, Long Term Services and
Supports, such as dressing, bathing or mobility assistance? See Brochure. q Yes q No
Ever applied before? q Yes If yes, which county ______________________________________ q No
STATE OF NEW JERSEY
Department of Human Services
Division of Medical Assistance and Health Services
NJ FamilyCare
Aged, Blind, Disabled Programs
SPOUSE INFORMATION
Complete Only if a Spouse is Applying
(
)
–
SECTION 2
Demographic Information for the Applicant 2 (Spouse)
Date of Birth: _____ _____ – _____ _____ – _____ _____ _____ _____ Sex: q Male q Female
Month Day Year
Citizenship Status:
  q US citizen or US national   q Naturalized or derived citizen (born outside of the US)
   If naturalized or derived citizen, enter
USCIS #_________________________________ and Certificate # ___________________________________
Certificate Type: q Naturalization Certificate q Certificate of Citizenship
Page 2 of 7
NJFC-ABD-APAUSP-1222
Spouse Information
If not a citizen, does the Applicant have an eligible immigration status?
Examples of eligible immigration status are:
  • Child under age 21 or pregnant woman: Lawfully residing in the US
  • Adult: Lawful Permanent Resident for 5 years OR qualified non-citizen, such as refugee or asylee
  q Yes, enter information below: q No
  Immigration document type________________________ Status type (optional)______________________
  The Applicant’s name as it appears on immigration document__________________________________
  USCIS or I-94 number________________________ Card or Passport Number________________________
  SEVIS ID or expiration date (optional) _______________________________________________
  Other (category code or country of origin) _________________________________________
  Has the Applicant lived in the US since 1996? q Yes q No
  Is the Applicant, or the Applicant’s spouse or parent, a veteran or an active-duty member
of the US military? q Yes q No
Social Security Number (SSN) ____ ____ ____ – ____ ____ –____ ____ ____ ____
If no SSN, has the Applicant applied for one?
q Yes q No enter reason: q Not needed for work q Religious reasons q Not eligible
If you have an SSN, providing your SSN and the SSN of other household members can speed up
the application process. We use SSNs to check income and other information to see who in your
household qualifies for health coverage. If someone wants help getting an SSN, call 1-800-772-1213
(TTY: 1-800-325-0778) or visit socialsecurity.gov. If you do not have an SSN, we will use other
documents to process your application.
Medicare ID Number: ____________________________________________________
Marital Status: q Single   q Married, Date _________________   q Divorced, Date ________________
q Widowed, Spouse’s Date of Death ______ q Child (under age 19) q Separated, Date __________
Your answers to questions about race and ethnicity can help us serve the community better.
They will not affect if you qualify for coverage or what services you can receive.
Race (Check all that apply). q Prefer not to answer
q White q Asian Indian q Korean q
Guamanian or Chamorro
q American Indian q Chinese q Vietnamese q Native Hawaiian
or Alaska Native q Filipino q Other Asian: q Samoan
q Black or African American q Japanese _______________ q Other Pacific Islander:
q Other:____________________ _________________________
Ethnicity (Check all that apply) q Prefer not to answer
q Mexican, Mexican American, q Puerto Rican q
Another Hispanic, Latino/a, or Spanish origin
Chicano/a q Cuban q Not of Hispanic, Latino/a, or Spanish origin
SECTION 2 - DEMOGRAPHIC INFORMATION FOR THE APPLICANT 2 (SPOUSE) - continued
SECTION 3
Intentionally left blank
Page 3 of 7
NJFC-ABD-APAUSP-1222
Spouse Information
Does the Applicant have Long Term Care Insurance? q Yes q No
Does the Applicant have a Department of Banking and Insurance
approved Long Term Care Partnership Policy? q Yes q No
If the Applicant answered yes to either of these questions, please provide a copy of the
policy/policies.
Does the Applicant have any other health insurance coverage? q Yes q No
If yes, list below the name of the health coverage, policy number, and any premium costs.
Name of Policy Policy Number Policy Premium
SECTION 5
Health Insurance Information - Applicant 2 (Spouse)
q Medicare Part A Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
q Medicare Part B Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
q Medicare Part C Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
q Medicare Part D Date Eligible ________________________________________
Does the Applicant pay a premium? q Yes Monthly Amount?_______________________   q No
SECTION 4
Assistance with Application
The applicant can choose someone to help them complete their application. We can
contact this person for more information. Select Below:
   q Authorized Representative
- Complete the Designation of Authorized Representative Form
(included).
   q
Power of Attorney
q
Legal Guardian
q
Attorney
q
Spouse
  
q
Other, please identify relationship ______________________________________________________
Provide the following information for this person:
Name
__________________________________________________________________________________________
Address
___________________________________ ____________________________ ________ ______________
Street City State Zip Code
Phone Number: __ __ __ __ __ __ __ __ __ __ E-mail Address: _____________________________________
(
)
–
Page 4 of 7
NJFC-ABD-APAUSP-1222
Spouse Information
Before signing this document, please read the rights and responsibilities outlined below. If there
is anything you do not understand or have questions about, please ask for clarification.
• If I am a third party applying on behalf of another person, as evidenced by a completed
Designation of Authorized Representative Form, my signature below indicates that this
application has been examined by, or read to, the applicant and, to the best of my knowledge,
the facts are true and complete. I understand that as a third party, I may be criminally
punished for knowingly providing false information.
• I understand that any information I give is subject to verification by the New Jersey Depart-
ment of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS)
for the Medicaid/NJ FamilyCare program, which is called “NJ FamilyCare” in this application.
I understand that my medical benefits may be reduced, denied, or stopped because of
information received through this verification.
SECTION 7
Applicant and Beneficiary Rights and Responsibilities
Has the Applicant 2 (Spouse) received unpaid medical bills within the past 3 months?
   q Yes q
No
Applicant’s current living arrangement, check all that apply.
  q Home: Own q Rent q q Living with Spouse q Nursing Facility
  q Assisted Living Facility q Residential Care Facility
  q Renting a room(s) in another person's residence q Living with Relative or Friend
q Other: Identify Living Arrangement: __________________________________________________________
List other people living with the Applicant; include name, date of birth, and relationship
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SECTION 6
Living Arrangements - Applicant 2 (Spouse)
Page 5 of 7
NJFC-ABD-APAUSP-1222
Spouse Information
• I understand that my situation is subject to verification from employers, financial sources, and
other third parties. I hereby give permission to NJ FamilyCare to contact any individual or
other source that may have knowledge about my circumstances, or the circumstances of a
person necessary for this application, for the purpose of verifying the statements I have
made. I give third parties permission to share information about me with authorized State,
State contractor, and county staff conducting investigations. Third parties include, but are not
limited to, financial institutions, credit reporting agencies, landlords, public housing agencies,
schools, utility companies, insurance agencies, employers, other governmental agencies, and
others, as necessary. I further authorize taxing authorities to release my tax information and
copies of my tax returns.
• I understand that DHS, including its operating Divisions, eligibility determining agencies,
government contractors, and other appropriate State of New Jersey agencies, may exchange
information relating to coverage to assist with this application, enrollment, administration, and
billing services.
• I understand that DMAHS has the authority to file a claim and lien against the estate of a
deceased Medicaid beneficiary, or former beneficiary, to recover all NJ FamilyCare payments
made on the beneficiary’s behalf to pay for health care coverage on or after age 55, regardless
of whether services were received. An NJ FamilyCare beneficiary’s estate may be required to
pay back DMAHS for those benefits. This includes monthly payments to, for example, a
managed care entity to secure health care coverage that you may not use in any month.
More information about Estate Recovery is available online at:
www.state.nj.us/humanservices/dmahs/clients/The_NJ_Medicaid_Program_and_Estate_
Recovery_What_You_Should_Know.pdf
• I agree to tell the eligibility determining agency immediately of changes to information entered
on this application including, but not limited to, the following:
1) If anyone receiving health benefits moves out of New Jersey;
2) Changes in where we live, get our mail, or any other contact information;
3) Changes in other health insurance coverage;
4) Changes in income and/or resources;
5) Improvement in medical condition, if disabled;
6) Marriage, divorce, or death of a spouse;
7) Addition or loss of household member, including pregnancy;
8) Sale or transfer of my home or other property; or,
9) Lawsuits and inheritances.
I understand that failure to report changes in application information, including those changes
listed above, may result in incorrectly paid benefits/coverage, and I may have to reimburse the
State of New Jersey for those benefits/coverage.
SECTION 7 - APPLICANT AND BENEFICIARY RIGHTS AND RESPONSIBILITIES - continued
Page 6 of 7
NJFC-ABD-APAUSP-1222
Spouse Information
• I understand that the outcome of this application may be shared with any provider who
provided services to the applicant/beneficiary during the period covered by the application.
• I understand, as a condition of being covered under Medicaid/NJ FamilyCare, that I have
assigned to the Commissioner of the Department of Human Services any rights to support for
the purpose of medical care as determined by a court or administrative order and any rights
to payment for medical care from a third party including, but not limited to, other health
insurance, legal settlements, or other third parties. I agree to release any medical information
needed by the NJ FamilyCare program, or others, for the purpose of paying or receiving
payment of medical bills. I agree to help in obtaining medical support and payments from
anyone who is legally responsible.
• I understand that I may request a fair hearing if I am not satisfied with the determination of
my application.
• I may be eligible for retroactive NJ FamilyCare coverage for unpaid, covered medical services
by Medicaid Fee-for-Service providers during the three (3) months prior to this application.
I further understand that these retroactive benefits will only apply to the month(s) that
eligibility requirements are met.
• I understand that an individual is only permitted to retain a certain amount in resources,
depending on the program’s eligibility requirements. I understand that if I am seeking Long
Term Services and Supports or services based on an institutional level of care, NJ FamilyCare
will examine transfers of resources that occurred within the 5 year look-back period before,
and any time after, my first date of applying for benefits.
• In order to redetermine my eligibility for NJ FamilyCare in the future, I agree to allow
NJ FamilyCare to use income data, including tax information. At time of renewal, NJ FamilyCare
will send me a renewal notice and let me indicate any changes in my or my household’s
eligibility information, and I can withdraw my request for benefits in writing at any time.
• I understand that if some or all of the individuals applying do not qualify for NJ FamilyCare
health care coverage, that they may be eligible for federal benefits and/or may explore private
health care coverage options through the State of New Jersey’s Health Insurance Marketplace
(Marketplace) at GetCovered.NJ.gov.
If this is the case, I authorize NJ FamilyCare and its contractors to give information contained in
this application to the Marketplace.
• I confirm that I have read and understood the NJ FamilyCare Privacy Policy available online at:
https://njfc.force.com/familycare/NJPrivacyNotice and the Notice of Privacy Practices available
online at: www.njfamilycare.org/docs/NJFC-HIPAA.pdf
• I understand that NJ FamilyCare may use or disclose protected health information about me or
my children if State or federal privacy laws require or allow it.
• I authorize my employer to release health benefits information to the NJ FamilyCare Office of
Premium Support.
• I will obey the law and regulations of NJ FamilyCare.
SECTION 7 - APPLICANT AND BENEFICIARY RIGHTS AND RESPONSIBILITIES - continued
Page 7 of 7
NJFC-ABD-APAUSP-1222
Spouse Information
• I know that under federal law, discrimination is not permitted on the basis of race, color,
national origin, sex, age, or disability. I can get more information, including how to file a
complaint of discrimination, by reading the NJ FamilyCare Non-Discrimination Statement
available online at: www.njfamilycare.org/docs/ndc_english.pdf
NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with
42 U.S.C. 1320b-7. The SSNs provided (including for a husband or wife, family members, or
dependents) will be used to associate records pertaining to applicants and other persons
necessary for the determination of eligibility, to verify identity, to verify income, and to
check other financial records, such as bank account information, to the extent it is useful
in verifying eligibility or the amount of medical assistance payments under 42 CFR 435.940
through 435.960 and to prevent duplicate participation or incorrectly paid benefits for you
and for persons in your household. The SSNs will be used in computer matching and
program reviews or audits. These procedures are designed to determine eligibility and to
identify persons who fraudulently or wrongfully participate in Medicaid and DHS programs.
Such persons may be subjected to criminal action, administrative claims, and/or possible
loss of all benefits. Failure to file for a SSN may result in disqualification for Medicaid.
NJ FamilyCare complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, sex, age or disability. If you speak any other language,
language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 711).
_______________________________________________________________________ ______________________
Applicant 2 (Spouse’s) Signature Date (mm/dd/yyyy)
__________________________________________________________________________ ________________________
Authorized Representative Name Relationship
__________________________________________________________________________ ________________________
Authorized Representative Signature Date (mm/dd/yyyy)
SECTION 8
Signature - Applicant 2 (Spouse)
The person who filled out this application must sign this application. If you’re an authorized
representative you may sign here, as long as you have provided the Designation of Authorized
Representative Form.
By signing below, I certify under penalty of perjury and false swearing that my answers on this
application are true, correct and complete to the best of my knowledge. I also certify that:
• I understand the questions and statements on this application.
• I understand that I may be subject to penalties under federal and state law if I provide false
or untrue information.
By signing below I also certify that I have read and understand the Applicant and Beneficiary
Rights and Responsibilities included.
This application can not be considered until it is received by the Eligibility Determining Agency.
SECTION 7 - APPLICANT AND BENEFICIARY RIGHTS AND RESPONSIBILITIES - continued
Intentionally left blank
Intentionally left blank
NJ Division of Elections - 02/16/16
New Jersey
Voter Registration Application
Need More Information? Check boxes below if you would like to receive more information about:
o
voting by mail
o
polling place accessibility
o
available election materials in
o
becoming a poll worker
o
voting if you have a disability,
this alternative language:
including visual impairment
For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)
Important Instructions for sections 5, 6 and 10
5 eistrants who are submittin this form by mail and are reisterin to vote for the 昀rst time: If you do not have any of the information
reuired by section 5, or the information you provide cannot be veri昀ed, you will be ased to provide a CO of a current and valid
photo ID, or a document with your name and current address on it to avoid havin to provide identi昀cation at the pollin place.
Note: ID Numbers are Con昀dential and will not be released by any governmental agency. Any person who uses such numbers
illegally shall be subject to criminal penalties.
 If you are homeless, you may complete section by providin a contact point or the location where you spend most of your time.
10 ou may declare a political party af昀liation or you may declare to be unaf昀liated, reardless of any prior party af昀liation. If you are a
previously af昀liated voter who wants to chane political party af昀liation or become unaf昀liated, you must 昀le this form no later than
55 days before the primary election in order to vote in the primary election. Completin section 10 is OTIONL and will not affect
the acceptance of your voter reistration application.
Chec boxes
o
New Registration
o
ddress Chane
o
olitical arty f昀liation
that apply:
o
Name Chane
o
Sinature pdate or Non-af昀liation Chane
Do you wish to declare a political party af昀liation
o
es, the party name is
.
(Optional)
o
No, I do not wish to be af昀liated with any political party.
If you DO NOT have a NJ Driver’s License or MVC Non-Driver
ID, provide the last 4 digits of your Social Security Number.
Are you a U.S. Citizen? o Yes o No
(If No, DO NOT complete this form)
Date of Birth
NJ Driver’s License Number or MVC Non-driver ID Number
Last Name
First Name
Middle Name or Initial
Suf昀x
(Jr., Sr., III)
Home Address (DO NOT use PO Box)
Apt.
Municipality
County Zip Code
Are you at least 17 years of age? o Yes o No
(If No, DO NOT complete this form)
Mailing Address if different from above
Last Address Registered to Vote (DO NOT use PO Box)
Former Name if Making Name Change
b. E-Mail Address (Optional)
Gender
o
Female
o
Male
Apt.
Municipality
County
Zip Code
Apt.
Municipality
County
Zip Code
8
10
2
3
4
5
6
7
Signature: Sign or mark and date on lines below
11
9
If applicant is unable to complete this form, print the
name and address of individual who completed this form.
Name
Date
Address
Clerk
Registration #
Of昀ce Time Stamp
o by mail
o in person
o
“I swear or af昀rm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”
Declaration - I swear or af昀rm that:
l
I am a U.S. Citizen
l I live at the above address
l I am at least 17 years old, and under-
stand that I may not vote until reaching
the age of 18.
FOR OFFICIAL
USE ONLY
1
Date
State
State
State
Please print clearly in ink. All information is required unless marked optional.
a. Day Phone Number (Optional)
X
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __
l I will have resided in the State and county
at least 30 days before the next election
l I am not on parole, probation or serving a
sentence due to a conviction for an indictable
offense under any federal or state laws
l I understand that any false or
fraudulent registration may subject
me to a 昀ne of up to $15,000,
imprisonment up to 5 years, or
both pursuant to R.S. 19:34-1
33
New Jersey
Voter Registration Information
FOLD
2
You can register to vote if:
n You are a United States citizen.
n You are at least 17 years of age.*
n You will be a resident of the State and county 30 days before the election.
n You are NOT currently serving a sentence, probation or parole because of a felony conviction.
*You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18.
Registration Deadline: 21 days before an election
Your County Commissioner of Registration will notify you if your application is accepted.
If it is not accepted, you will be noti昀ed on how to complete and/or correct the application.
Questions? visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837)
TAPE HERE
3
Important: Print out at 100% - DO NOT REDUCE. Fold as illustrated to ensure proper mailing.
Put both pages
together as shown
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New Jersey
Voter Registration
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NJ DIVISION OF ELECTIONS
PO BOX 304
TRENTON NJ 08625-9983
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You can register to vote if:
n You are a United States citizen
n You will be 18 years of age by the next election
n You will be a resident of the county 30 days before the election
n You are NOT currently serving a sentence, probation or parole because of a felony conviction
Registration Deadline: 21 days before an election
Your County Commissioner of Registration will notify you if your application is accepted.
If it is not accepted, you will be notified on how to complete and/or correct the application.
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