STATE oF NEW JERSEY NJ FamilyCare Division of …

1 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?

2 Yes If yes, which county _____ NoHas the applicant applied for Supplemental Security Income (SSI)? Yes If yes, when ____ ____ ____ ____ ____ ____ NoMonthYear() APPLICATIONSECTION 2 Demographic Information for the ApplicantDate of Birth: ____ ____ ____ ____ ____ ____ ____ ____ Sex: Male Female Month DayYearCitizenship Status: US Citizen Refugee Asylee Legal Alien _____Date of Entry Not Lawfully AdmittedPlace of Birth: City _____ STATE _____ Country_____Social SecurityMedicareNumber: ____ ____ ____ ____ ____ ____ ____ ____ ____ID Number: _____Marital Status: Single Married, Date _____ Divorced, Date _____ Widowed Separated, Date _____ Child (under age 19)Page 2 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # _____Spouse's Name: _____ _____ _____ _____LastFirstMiddle Maiden NameSpouse s Date of Birth.

3 ____ ____ ____ ____ ____ ____ ____ ____Month DayYearSpouse s Social Security Number: ____ ____ ____ ____ ____ ____ ____ ____ ____Is this person also applying for the Aged, Blind, disabled Programs? No Yes, please complete the Spouse Information 3 Spouse s NameSECTION 4 Assistance with ApplicationThe applicant can choose someone to help them complete their application. We cancontact this person for more information. Select Below: Authorized Representative-Complete the Designation of Authorized Representative Form (included). Power of Attorney Legal Guardian Attorney Spouse other, please identify relationship _____Provide the following information for this person:Name_____Address _____ _____ _____ _____StreetCity STATE Zip Code Phone Number: __ __ __ __ __ __ __ __ __ __ E-mail Address: _____() Also include if divorced, separated or widowed in the past 5 3 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # _____SECTION 5 Health Insurance Information Medicare Part A Date Eligible _____Does the Applicant pay a premium?

4 Yes How Much?_____ No Medicare Part B Date Eligible _____Does the Applicant pay a premium? Yes How Much?_____ No Medicare Part C Date Eligible _____Does the Applicant pay a premium? Yes How Much?_____ No Medicare Part D Date Eligible _____Does the Applicant pay a premium? Yes How Much?_____ NoDoes the Applicant have any other health insurance coverage? Yes NoIf yes, list below the name of the health coverage, policy number, and any premium costs Does the Applicant have Long Term Care Insurance? Yes NoDoes the Applicant have a New JERSEY Department of Banking and Insurance approved Long Term Care Partnership Policy? Yes NoIf the Applicant answered yes to either of these questions, please provide a copy of the policy(s).Name of PolicyPolicy NumberPolicy PremiumPage 4 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # _____Applicant s current living arrangement, check all that apply.

5 Home: own Rent Living with Spouse Nursing Facility Assisted Living Facility Residential Care Facility Renting a room(s) in another person's residence Living with Relative or Friend other: Living Arrangement: _____List other people living with the Applicant; include name, age and relationship_____SECTION 6 Living ArrangementsSECTION 7 Income InformationThis section talks about the income that the Applicant receives. Income is any cash or in kind support that can be used for food or can be wages, tips, and commissions. Income can also be government benefits (such asSocial Security Benefit), interest or dividends. I do not have any income. If not, how do you pay your bills? _____Current Job & Income Information EmployedIfApplicant iscurrentlyemployed,tellus about Applicant Self-employedSkiptoquestion 10. Not employedSkiptoquestion JOB1 _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ (before taxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly$ worked eachWEEK _____() Does the Applicant have any income from employment?

6 Yes NoPage 5 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # _____CURRENT JOB2: (If theApplicanthasmore jobsandneedsmore space,attachanother sheetofpaper.) _____ _____ _____ _____ _____ _____ _____ _____ _____ (before taxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly$ hours worked each WEEK the past year, didthe Applicant: Changejobs Stopworking Startworking fewer hours self-employed, answer the much net income (profits once business expenses are paid) will the Applicantget from this self-employment this month? $ INCOME THIS MONTH:Check all that apply, and give the amount and how often does the Applicant get it. None Unemployment $_____ How often? _____ Pensions $_____ How often? _____ Social Security $_____ How often? _____ Retirement accounts $_____ How often? _____ Alimony received $_____ How often?

7 _____ Child Support $_____ How often? _____ Work Compensation/Disability $_____ How often? _____ Inheritance $_____ How often? _____ Net rental/royalty $_____ How often? _____ Annuity $_____ How often? _____ other income $_____ How often? _____ :Complete only if your income changes from month to you don t expect changes to your monthly income, skip to the next total income this year $ _____ Your total income next year (if you think it will be different) $ _____ () CURRENT JOB2:(If the Spouse has more jobs and need more space, attach another sheet of paper.) _____ _____ _____ _____ _____ _____ _____ _____ _____ (before taxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly $ hours worked each WEEK the past year, did the Spouse: Changejobs Stopworking Start working fewer hours Spouse is self-employed, answer the following much net income (profits once business expenses are paid)will the Spouse get from this self-employment this month?

8 $_____Page 6 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # _____Please complete the following section with all information on Spouse s incomeSECTION 7aSpouse s IncomeCurrent Job & Income Information EmployedIfSpouse iscurrentlyemployed,tellus about Spouse Self-employedSkiptoquestion 22. Not employedSkiptoquestion JOB1 _____ _____ _____ _____ _____ _____ _____ _____ _____ (before taxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly$ hours worked each WEEK _____( ) ( ) Page 7 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # INCOME THIS MONTH:Check all that apply, and give the amount and how often does the Spouse get it. None Unemployment $_____ How often?

9 _____ Pensions $_____ How often? _____ Social Security $_____ How often? _____ Retirement accounts $_____ How often? _____ Alimony received $_____ How often? _____ Child Support $_____ How often? _____ Work Compensation/Disability $_____ How often? _____ Inheritance $_____ How often? _____ Net rental/royalty $_____ How often? _____ Annuity $_____ How often? _____ other income $_____ How often? _____ :Complete only if your income changes from month to you don t expect changes to your Spouse s income, skip to the next s total income this year $ _____ Spouse s total income next year (if you think it will be different) $ _____ Page 8 of 16 NJFC-ABD-AP-1017 Application for Aged, Blind and disabled ProgramsFOR OFFICE USE ONLYDate Applied _____Registration # _____SECTION 8 Resources for Applicant and Applicant s SpousePlease detail all resources owned in full or in part by the Applicant, and/or the Applicant sSpouse.

10 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 sSpouse within 60 months of application date. Account Name_____Bank Address _____Name(s) on Account _____Account or Certificate # _____ Current Value _____If Closed, Date Closed & Value _____Account Name_____Bank Address _____Name(s) on Account _____Account or Certificate # _____ Current Value _____If Closed, Date Closed & Value _____Account Name_____Bank Address _____Name(s) on Account _____Account or Certificate # _____ Current Value _____If Closed, Date Closed & Value _____Account Name_____Bank 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 16 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.