INSTRUCTIONS FOR COMPLETING THE …

New Jersey Department of Health AIDS Drug Distribution Program (ADDP) and Health Insurance Continuation Program (HICP). PO Box 722. Trenton, NJ 08625-0722. INSTRUCTIONS FOR COMPLETING . THE APPLICATION FOR participation IN THE ADDP AND/OR HICP PROGRAM. Before you begin COMPLETING the application form, please take a few minutes to review these specific INSTRUCTIONS . While many of the questions are self-explanatory, some require additional clarification to be completed correctly. If you need assistance COMPLETING this application, call toll free 1-877-613-4533 for ADDP questions or 1-800-353-3232 for HICP questions. SECTION I - APPLICANT INFORMATION. Enter your principal place of residence. Seasonal or temporary residence in New Jersey, of whatever duration, does not constitute residency. Include two (2) proofs of residence, one of which must be no more than 6 months old. Sample proofs of residency include: Motor Vehicle records ( , valid Driver's License) Social Security records Lease or mortgage Post Office records Landlord's records and rent receipts Photo ID from county Public utility records and receipts (electric, gas, phone bill) If you are homeless, have case manager/social Records of social agencies, public or private worker provide support documentation on facility Employment records letterhead You must submit your Social Security number which will be used to create a unique identifier to track your applica

instructions for completing the application for participation in the aids drug distribution program and/or health insurance continuation program

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