STATE oF NEW JERSEY NJ FamilyCare Division of …

Page 1 of 16 NJFC-ABD-AP-1017 FOR OFFICE USE ONLYHMo choice _____Date Applied _____Registration # _____STATE oF NEW JERSEYD epartment of Human ServicesDivision of Medical Assistance and Health ServicesNJ FamilyCare aged , Blind, Disabled ProgramsSECTION 1 ApplicantApplicant s Name: _____ _____ _____ _____LastFirstMiddle Maiden NameHome Address: _____ _____ _____ _____StreetCity STATE Zip Code Current Mailing Address (if different from above):_____ _____ _____ _____StreetCity STATE Zip Code If Applicant has not lived at the Home Address for 5 years, tell us the previous address:(Attach additional information if needed)_____ _____ _____ _____StreetCity STATE Zip Code Applicant s Applicant s Phone Number: __ __ __ __ __ __ __ __ __ __ E-mail Address: _____Is the Applicant Blind or Disabled: Yes If yes, as of what date: _____ NoApplicant in need of Long Term Services and Supports (see Brochure) Yes NoHave you ever applied for Long Term Services and Supports before?

Page 3 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and Disabled Programs FOR OFFICE USE ONLY Date Applied _____ Registration # _____

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