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Question	Answer
Form Name	Njfamilycare Application
Form Length	16 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min
Other names	nj familycare application, nj familycare renewal, nj familycare renewal application 2020 pdf, njfamilycare org application

Application for Health Coverage & Help Paying Costs

Use this application to see what coverage choices you qualify for

•Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP), known as NJ FamilyCare

•

you stay well

•A new tax credit that can help pay your premiums for health coverage

	Who can use this	• Use this application to apply for anyone in your family.
	application?	• Apply even if you or your child already has health coverage. You could be
	application?	eligible for lower-cost or free coverage.
		eligible for lower-cost or free coverage.
		• If you’re single, you may be able to use a short form.
		Visit njfamilycare.org.
		• Families that include immigrants can apply. You can apply for your

			immigration status or chances of becoming a permanent resident or
			citizen.
		•	d to
			complete Appendix C.
TO KNOW	Apply faster	Apply faster online at njfamilycare.org.
	online
	What you may	• Social Security Numbers (or document numbers for any legal immigrants

THINGS			who need insurance)
	need to apply		who need insurance)
		• Employer and income information for everyone in your family (for


			example, from paystubs, W-2 forms, or wage and tax statements)
		• Policy numbers for any current health insurance
		• Information about any job-related health insurance available to your family
	Why do we ask for	We ask about income and other information to let you know what coverage
	this information?	you qualify for and if you can get any help paying for it. We’ll keep all the
	this information?	information you provide private and secure, as required by law. To view

		the Privacy Act Statement, go to njfamilycare.org.
	What happens next?	Send your complete, signed application to the address on page 7.
		If you don’t have all the information we ask for, sign and submit
		your application anyway. We’ll follow-up with you within 1–2 weeks. You’ll
		get instructions on the next steps to complete your health coverage. If you
		don’t hear from us, visit njfamilycare.org or call 1-800-701-0710. Filling out
		this application doesn’t mean you have to buy health coverage.
	Get help with this	•	Online: njfamilycare.org
	application	• Phone: Call our Help Center at 1-800-701-0710.
	application

•In person: There may be counselors in your area who can help. Visit our website or call 1-800-701-0710 for more information.

•En Español: Llame a nuestro centro de ayuda gratis al

1-800-701-0710.

	NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or	E-0919
	disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).	-
		NJFC-APP
		NJFC-APP

STEP 1 Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suﬃx

2. Home address (Leave blank if you don’t have one.)

3. Apartment or suite number

4. City

5. State

6. ZIP code

7. County

8. Current mailing address (if diﬀerent from home address)

9. Apartment or suite number

10. City

11. State

12. ZIP code

13. County

14. Phone number
(	)	–

15. Other phone number

(

)

–

16. Do you want to get information about this application by email? Yes No

Email address:

17. What is your preferred spoken or written language (if not English)?

STEP 2 Tell us about your family.

Family Planning (Plan First Program)

If any person on this application is not eligible for NJ FamilyCare, would you like them to be evaluated for family planning services (Plan First Program)?

Yes	Check here for all applicants on this application to be evaluated for family planning services.

Plan First is a program for women and men that provides only family planning and related services (such as birth control and reproductive health care). Family planning services do not provide minimum essential health care coverage (such as routine care).

Who do you need to include on this application?

DO Include:

•Yourself

•Your spouse

•Your children under 21 who live with you

•Your unmarried partner who needs health coverage

•Anyone you include on your tax return, even if they don’t live with you

•Anyone else under 21 who you take care of and lives with you

You DON’T have to include:

•Your unmarried partner who doesn’t need health coverage

•Your unmarried partner’s children

•

(if you’re over 21)

•

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family, you’ll need to make a copy of the pages and attach them.

You don’t need to provide immigration status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.

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: 1-800-701-0720).

Page 1 of 7

NJFC-APP-E-0919

STEP 2: PERSON 1 (Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you

with you.

1. First name, Middle name, Last name, & Suﬃx

2. Relationship to you?

SELF

3.Date of birth (mm/dd/yyyy)

5.Sex Male Female

4. Citizenship Status:	US Citizen	Refugee	Asylee	Not Lawfully Admitted
Legal Alien ____________ USCIS/Alien #__________________________				Immigration Card #__________________________
Date of Entry

Oﬃcial Name on Immigration Document/Card (AKA) ____________________________________________________________

6. Social Security number (SSN)						-				-

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

7a. Check this box if you plan to ﬁle a federal income tax return NEXT YEAR.

(You can still apply for health insurance even if you don’t ﬁle a federal income tax return.)

Will you ﬁle jointly with your spouse?

Yes No

If yes, name of spouse:

Will you claim any dependents on your tax return? If yes, list name(s) of dependents:

Yes No

7b. Check this box if you will be claimed as a dependent on someone’s federal tax return.

If yes, please list the name of the tax ﬁler:

How are you related to the tax ﬁler?

8. Are you pregnant? Yes

No a.If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

9.Do you need health coverage?

(Even if you have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below.

NO. If no, SKIP to the income questions on page 3. Leave the rest of this page blank.

10. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc) or live in a medical facility or nursing home?

Yes

11. Do you want help paying for medical bills from the last 3 months?

Yes

12. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?

Yes

13. Are you a full-time student?

Yes

14. Were you in foster care at age 18 or older?

Yes

15.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

16.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro Samoan

Other

Page 2 of 7

NJFC-APP-E-0919

STEP 2: PERSON 1

(Continue with yourself)

Current Job & Income Information

Employed

Not employed

Self-employed

If you’re currently employed, tell us

Skip to question 27.

Skip to question 26.

about your income. Start with question

17.

CURRENT JOB 1:

17. Employer name and address

18. Employer phone number

(

)

–

19. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

20. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)

21. Employer name and address

22. Employer phone number

(

)

–

23. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

24. Average hours worked each WEEK

25. In the past year, did you:

Change jobs Stop working

Start working fewer hours

None of these

26.If self-employed, answer the following questions:

a. Type of work	b. How much net income (proﬁts once business expenses are
	paid) will you get from this self-employment this month?
	$

27.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None			Net farming/ﬁshing
Unemployment	$	How often?	Net farming/ﬁshing	$	How often?
Unemployment	$	How often?	Net rental/royalty	$	How often?
Pensions	$	How often?	Net rental/royalty	$	How often?
			Other income	$	How often?

Social Security	$	How often?
Social Security	$	How often?	Type:
Retirement accounts	$	How often?	Type:
Retirement accounts	$	How often?
Alimony received	$	How often?

28. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).

Alimony paid

How often?

Other deductions

How often?

Student loan interest

How often?

Type:

29.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 person.

Your total income this year	Your total income next
$	$

THANKS! This is all we need to know about you.

Page 3 of 7

NJFC-APP-E-0919

Guamanian or Chamorro Samoan

Other

STEP 2: PERSON 2	If you have more than two people to include, make a

	copy of Step 2: Person 2 (pages 4 and 5) and complete.

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you

with you.

1. First name, Middle name, Last name, & Suﬃx

2. Relationship to you?

3. Date of birth (mm/dd/yyyy)

5. Sex

Male

Female

4. Citizenship Status:	US Citizen	Refugee	Asylee	Not Lawfully Admitted
Legal Alien ____________ USCIS/Alien #__________________________				Immigration Card #__________________________
Date of Entry

Oﬃcial Name on Immigration Document/Card (AKA) ____________________________________________________________

6.	Social Security number (SSN)	-	-		We need this if you want health coverage and have an SSN.
6.	Social Security number (SSN)	-	-		We need this if you want health coverage and have an SSN.
7.	Does PERSON 2 live at the same address as you?		Yes	No
	If no, list address:

8a. Check this box if PERSON 2 plans to ﬁle a federal income tax return NEXT YEAR.

(You can still apply for health insurance even if you don’t ﬁle a federal income tax return.)

Will PERSON 2 ﬁle jointly with their spouse?

If yes, name of spouse:

Yes No

8b.

Will PERSON 2 claim any dependents on their tax return? Yes No

If yes, list name(s) of dependents:

Check this box if PERSON 2 plans to be claimed as a dependent on someone’s federal tax return. If yes, please list the name of the tax ﬁler:

How is PERSON 2 related to the tax ﬁler?

9. Is PERSON 2 pregnant?

Yes

No a. If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

10.Does PERSON 2 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below.	NO. If no, SKIP to the income questions on page 5.
	Leave the rest of this page blank.

11.Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No

12. Does PERSON 2 want help paying for		13. Does PERSON 2 live with at least one child under			14. Was PERSON 2 in foster care at age

medical bills from the last 3 months?		the age of 19, and are they the main person			18 or older?
Yes	No	taking care of this child?	Yes	No	Yes	No

Please answer the following questions if PERSON 2 is 22 or younger:

16.Is PERSON 2 a full-time student? Yes No

17.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

18.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Now, tell us about any income from PERSON 2

Page 4 of 7

NJFC-APP-E-0919

STEP 2: PERSON 2

Current Job & Income Information

Employed	Not employed	Self-employed
If you’re currently employed, tell us	Skip to question 29.	Skip to question 28.
about your income. Start with question
19.

CURRENT JOB 1:

19. Employer name and address							20. Employer phone number
							(	)	–

21. Wages/tips (before taxes)	Hourly	Weekly	Every 2 weeks	Twice a month	Monthly			Yearly
$

22. Average hours worked each WEEK

CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
23. Employer name and address							24. Employer phone number
							(	)	–

25. Wages/tips (before taxes)	Hourly	Weekly	Every 2 weeks	Twice a month	Monthly			Yearly
$

26. Average hours worked each WEEK

27. In the past year, did PERSON 2:		Change jobs	Stop working	Start working fewer hours		None of these

28.If self-employed, answer the following questions:

a. Type of work	b. How much net income (proﬁts once business expenses are
	paid) will you get from this self-employment this month?
	$

29.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

None
Unemployment	$	How often?	Net farming/ﬁshing	$	How often?
Unemployment	$	How often?	Net rental/royalty	$	How often?
Pensions	$	How often?	Net rental/royalty	$	How often?
Pensions	$	How often?	Other income	$	How often?
Social Security	$	How often?	Other income	$	How often?
Social Security	$	How often?	Type:
Retirement accounts	$	How often?	Type:
Retirement accounts	$	How often?
Alimony received	$	How often?
Alimony received	$	How often?

30. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 29b).

Alimony paid

How often?

Other deductions

How often?

Student loan interest

How often?

Type:

31.YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.

If you don’t expect changes to PERSON 2’s monthly income, add another person or skip to the next section.

PERSON 2’s total income this year	PERSON 2’s total income next year
$	$

THANKS! This is all we need to know about PERSON 2.

Page 5 of 7

NJFC-APP-E-0919

STEP 3 Native American Indian or Alaska Native (AI/AN) family member(s)

1.Are you or is anyone in your family Native American Indian or Alaska Native?

If No, skip to Step 4. Yes. If yes, go to Appendix B.

STEP 4 Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1.Is anyone enrolled in health coverage now from the following?

YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.

NO.

Medicaid

Employer insurance

NJ FamilyCare

Name of health insurance:

Policy number:

Medicare

Is this COBRA coverage?

Yes

TRICARE (Don’t check if you have direct care or Line of Duty)

Is this a retiree health plan?

Yes

Other

VA health care programs

Name of health insurance:

Policy number:

Peace Corps

Plan First (Family Planning)

Yes

2.Is anyone listed on this application oﬀered health coverage from a job? Check yes even if the coverage is from someone else’s job, such as a parent or spouse.

YES. If yes, you’ll need to have your employer complete Appendix A and return to address provided.

NO. If no, continue to Step 5.

STEP 5 Select your Health Plan

If you need assistance selecting your Health Plan, contact a Health Beneﬁts Coordinator at 1-800-701-0710, TTY 1-800-701-0720.

Choose one:

Aetna Better Health® of New Jersey (Available in ALL counties)

Amerigroup New Jersey, Inc. (Available in ALL counties)

Horizon NJ Health (Available in ALL counties)

UnitedHealthcare Community Plan (Available in ALL counties)

WellCare Health Plans of New Jersey (Available in ALL counties, except Hunterdon county)

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.

FOR OFFICE USE ONLY

Name _____________________________________________________________

Case # _________________________________________________________________

Page 6 of 7

NJFC-APP-E-0919

STEP 6 Read & sign this application.

•I understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it.

•

•I understand that the outcome of this application may be shared with any Provider providing services or who provided

•I understand that I must tell NJ FamilyCare immediately about any changes in my information, such as a change in income, address, family size, if someone in my household is expecting a baby, or if anyone in my household who applied for

member(s) of my household. I know that I must call 1-800-701-0710 (TTY 1-800-701-0720) to report any changes.

•I authorize the NJ Division of Taxation to release my tax return information to NJ FamilyCare.

•I also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, NJ Division of Taxation, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and I can opt out at any time.

If anyone on this application is eligible for NJ FamilyCare

•I am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the NJ FamilyCare agency rights to pursue and get medical support

from a spouse or parent.
• Does any child on this application have a parent living outside of the home?	Yes	No

•If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell NJ FamilyCare and I may not have to cooperate.

My right to appeal

If I think NJ FamilyCare has made a mistake, I can appeal its decision. To appeal means to tell someone at NJ FamilyCare that I

NJ FamilyCare at 1-800-701-0710. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Estate Recovery

I understand that Medicaid payments for services received on or after age 55 may be reimbursable to the State of New Jersey

be limited to, capitation payments made to a managed care organization (MCO) or transportation broker for health coverage,

transportation broker. For more information about Estate Recovery, visit http://www.state.nj.us/humanservices/dmahs/ clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_You_Should_Know.pdf

Sign this application.

may sign here, as long as you have provided the information required in Appendix C.

Signature

Date (mm/dd/yyyy)

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

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 preventing duplicate

audits. These procedures are designed to determine eligibility and to identify persons who fraudulently or wrongfully participate in Medicaid and DMAHS

STEP 7 Mail Completed Application.

Mail your signed application to: NJ FamilyCare

PO BOX 8367

TRENTON, NJ 08650-9802

Page 7 of 7

NJFC-APP-E-0919

APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this

Tell us about the job

You need to include this page when you send in your application.

EMPLOYEE Information

1. Employee name (First, Middle, Last)

2. Employee Social Security number

EMPLOYER Information

3. Employer name

4. Employer Identiﬁcation Number (EIN)

5. Employer address

6. Employer phone number

(

)

–

7. City

8. State

9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above)

12. Email address

(

)

–

13. A

Yes (Continue)

13a. If you’re in a waiting or probationary period, when can you enroll in coverage?

List the names of anyone else who is eligible for coverage from this job.

(mm/dd/yyyy)

Name:

No (Stop here and go to Step 5 in the application)

Tell us about the health plan

d*? Yes No

15.For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a.How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

16.What change will the employer make for the new plan year (if known)?

Employer

the employee that meets the minimum value standard.* (Premium should reﬂect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed beneﬁt costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este	-E-0919
formulario en Español, llame 1-800-701-0710 . If you need help in a language other than English, call 1-800-701-0710 and tell the	-APP
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-701-0720.	NJFC

APPENDIX B

Native American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs.

Tell us about your Native American Indian or Alaska Native family member(s).

Native American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSON 1

AI/AN PERSON 2

1. Name

First

Middle

First

Middle

(First name, Middle name, Last name)

Last

2. Member of a federally recognized tribe?

Yes

If yes, tribe name

3. Has this person ever gotten a service from

Yes

the Indian Health Service, a tribal health

program, or urban Indian health program,

or through a referral from one of these

If no, is this person eligible to get

programs?

services from the Indian Health

Service, tribal health programs, or

urban Indian health programs, or

through a referral from one of these

programs?

Yes

4. Certain money received may not be

counted for NJ FamilyCare. List any

income (amount and how often) reported

How often?

on your application that includes money

from these sources:

•Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

•Payments from natural resources, farming, ranching, ﬁshing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

•Money from selling things that have cultural signiﬁcance

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710 . If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-701-0720.

NJFC-APP-E-0919

APPENDIX C

Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact NJ FamilyCare. If you’re a legally appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

2. Address				3. Apartment or suite number

4. City			5. State	6.	ZIP code

7. Phone number
(	)	–

8. Organization name				9.	ID number (if applicable)

By signing, you allow this person to sign your application, getinformation about this application, and act for you on all future matters with this agency.

10. Your signature	11. Date (mm/dd/yyyy)

For certiﬁed application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certiﬁed application counselor, navigator, agent, or broker ﬁlling out this application for somebody else.

1.Application start date (mm/dd/yyyy)

2.First name, Middle name, Last name, &

3. Organization name	4. ID number (if applicable)

NJFC-APP-E-0919

STATE OF NEW JERSEY

Department of Human Services

Division of Medical Assistance and Health Services

Non-DiscriminationStatement

DiscriminationisAgainsttheLaw

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. NJ FamilyCare does not exclude people or treat them differently because of race, color, national origin, sex, age or disability.

NJFamilyCare:

•Provides free aids and services to people with disabilities to communicate effectively with us, such as:

–Qualified sign language interpreters

–Written information in other formats (large print, audio, accessible electronic formats, other formats)

•Provides free language services to people whose primary language is not English, such as:

–Qualified interpreters

–Information written in other languages

If you need these services, please contact 1-800-701-0710 (TTY: 1-800-701-0720).

If you believe that NJ FamilyCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, sex, age or disability, you can file a grievance with the NJ FamilyCare Civil Rights Coordinator via the following: NJ Civil Rights Coordinator, NJ Department of Human Services, Office of Legal and RegulatoryAffairs, P.O. Box 700, Trenton, NJ 08625-0700, 1-888-347-5345 or email: DHS-CO.OLRA@dhs.state.nj.us. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also electronically file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services SW, Room 509F, HHH Building

200 IndependenceAvenue Washington, D.C. 20201

1-800-368-1019, 1-800-537-7697 (TDD)

U.S. Department of Health and Human Services complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

NJFC-NDS-0719

New Jersey Non-Discrimination Statement

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New Jersey

Voter Registration Application

Please print clearly in ink. All information is required unless marked optional.

Check boxes

o New Registration

o Address Change

o Political Party Affiliation

FOR OFFICIAL

that apply:

o Name Change

o Signature Update or Non-affiliation Change

USE ONLY

Are you a U.S. Citizen? o Yes o No

Are you at least 17 years of age? o Yes o No

Clerk

(If No, DO NOT complete this form)

Last Name

First Name

Middle Name or Initial

Suffix (Jr., Sr., III)

Registration #

Date of Birth

Office Time Stamp

NJ Driver’s License Number or MVC Non-driver ID Number

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. __ __ __ __

o“I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”

6	Home Address (DO NOT use PO Box)	Apt.	Municipality	County	State	Zip Code

7	Mailing Address if different from above	Apt.	Municipality	County	State	Zip Code

8	Last Address Registered to Vote (DONOTusePOBox)	Apt.	Municipality	County	State	Zip Code	o by mail
							o in person

9Former Name if Making Name Change

a.Day Phone Number (Optional)

b.E-MailAddress (Optional)

10 Do you wish to declare a political party affiliation?	o Yes, the party name is		.
(Optional)	o No, I do not wish to be affiliated with any political party.

11Gender o Female o Male

Declaration - I swear or affirm that:

• I am a U.S. Citizen

• I live at the above address

• I am at least 17 years old, and under- stand that I may not vote until reaching the age of 18.

• I will have resided in the State and county

at least 30 days before the next election

• I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws

• I understand that any false or

fraudulent registration may subject me to a fine of up to $15,000, imprisonment up to 5 years, or

both pursuant to R.S. 19:34-1

Signature: Sign or mark and date on lines below

Date

If applicant is unable to complete this form, print the name and address of individual who completed this form.

Name

Date

Address

Important Instructions for sections 5, 6 and 10

5)Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place.

Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties.

6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of your time.

10)You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 10 is OPTIONAL and will not affect the acceptance of your 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)

NJ Division of Elections - 02/16/16

New Jersey

Voter Registration Information

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 notified 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)

FOLD

Important: Print out at 100% - DO NOT REDUCE. Fold as illustrated to ensure proper mailing.

New Jersey

Voter Registration

You can register to vote if:

nYou are a United States citizen

nYou will be 18 years of age by the next election

nYou will be a resident of the county 30 days before the election

nYou are NOT currently serving a sentence, probation orparole 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.

FOLD

Put both pages	1 fold top down	2 fold bottom up	3 Tape top shut
together as shown

HERE TAPE

15. Did PERSON 2 have insurance through a job and lose it within the past 3 months?

a. If yes, end date:

b. Reason the insurance ended:

a. If yes, end date:

b. Reason the insurance ended: