FINANCIAL ASSISTANCE PROGRAM APPLICATION
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1 Attachment C FINANCIAL ASSISTANCE PROGRAM APPLICATION SECTION I: APPLICANT Last Name Maiden Name First Name M.I. SSN City State Zip Code Home Phone Work Phone Family Member Dependent Residency (First and Last Name) (Yes) (No) Relationship Birthdate SSN (Citizen) (Legal Alien) SECTION II: OTHER ASSISTANCE PROGRAM ELIGIBILITY Medicaid Referral? If "Yes," date denial received: CHP+ Referral? If "Yes," date denial received: If a client is disabled, receiving cash assistance or Social Security income, is pregnant, or is under the age of 6, a Medicaid denial is required before completing the NJFAP Application. CICP Eligible? Eligibility Period Eligible for Other State or Federal Programs? SECTION III: HEALTH INSURANCE (Please attach a copy of client's health insurance policy or a copy of both sides of the client's insurance card, if available.) I understand that NJFAP can help patients who have other medical coverage, like primary and/or secondary insurance, and that those benefits must be used up before I can use NJFAP. However, NJFAP can help me with any co-insurance, deductibles, or co-paym Type of Policy Name of Insurance Policy Telephone Number: Claim Submission Policy Number Policyholder's SSN Group # Effective Date End Date Policyholder's Name (Last, First) Policyholder's Employer Name SECTION IV: EMPLOYMENT Name of Employer n/a Name of Employer Work Phone Work Phone
2 SECTION V: OTHER INCOME SECTION VI: CURRENT MEDICAL EXPENSES TOTALS FROM "WORKSHEET" This section allows deduction of total household medical bill payments 1 Unearned Income for the current calendar year with documentation. 2 Self-Employment Income 3 In-Kind Income 6 Total Current Year Medical Expenses*: 4 Monthly Expense Income 5 Total Other Income *Must be documented by canceled checks, EOBs, or payment contracts. SECTION VII: HOUSEHOLD EMPLOYMENT INCOME/GRAND TOTAL INCOME Prior 3-Month's Earnings Annualized Total Prior Year Tax Return Total Gross Employment Income **The Employment Income Total is the greater of the Annualized Total or the Prior Year Tax Return Total. ***If unemployed, greater of Employment Income Total -OR- Line 5. If employed greater of Line 5 + Annualized Total -OR- Prior Year Tax Return Total. 7 GRAND TOTAL INCOME***: LESS LINE 6: Employment Income Total** SECTION VIII: CALCULATING EQUITY IN ASSETS RESOURCE Value Balance Owed Equity # of Vehicles Protection 8 Liquid Resources 9 Vehicle Equity 10 Real Estate 11 Business Equity Available Equity 12 Total Available Equity in Resources (Lines ) TOTAL RESOURCES 13 Less Family Size Deduction Family Size X 2, Equity in Resources (Line 12 minus Line 13; if a negative number, then this equals zero) SECTION IV: TOTAL AVAILABLE ASSETS 15 Total Family Financial Status (Lines 7+14) PENALTY CLAUSE, CONFIRMATION STATEMENT, AND AUTHORIZATION FOR RELEASE OF INFORMATION I declare that the information given on this application is true. I understand that if I make untrue statements on this application, I will no longer be accepted on NJFA NJFAP Rating: Inpatient Copayment Outpatient Copayment Prescription Copayment: Date: Notes: Print or Type Applicant Name Applicant Signature and Date Print or Type Name of Individual Completing This Form Financial Counselor's Signature and Date Manager Signature and Date
3 WORKSHEET UNEARNED INCOME CALCULATION Payment Sources Unemployment Compensation Old Age Pension Supplemental Security Income (SSI/SSDI) Aid to Needy & Disabled Pension Plan (name plans): Monthly Amount x 12 x 12 x 12 x 12 x 12 Commissions, bonuses, gifts, & tips Alimony received Income from Trusts or Annuities Rental income Interest income Work Study Income Monetary gains Settlements (do not annualize) Tax Refunds (do not annualize) Net Gambling Winnings (do not annualize) x 12 x 12 x 12 x 12 x 12 x 12 x 12 Total Unearned Income (Transfer to Section V, Line 1)
4 SELF-EMPLOYMENT INCOME CALCULATION: BUSINESS 1 3-Month Amount Prior 12 Months (from tax return) Gross Business Deposits Business Expenses Salaries/Wages (Line 26*; excludes amounts paid to self) Benefits (Line 14*) Insurance (Line 15*) Rent (Line 20*) Cost of Goods Sold (Line 4*) Mortgage Interest (Line 16a*) Taxes (Line 23*) Maintenance (Line 21*) Utilities (Line 25*) Supplies (Line 22*) Professional Services (Line 17*) Advertising (Line 8*) Education/Licensing/Certification Bad Debts (Line 9*) Office Expense (Line 18*) Car/Truck Expenses (Line 10*) Other Total Expenses GROSS DEPOSITS (TOTAL EXPENSES) x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 NET PROFIT A B *All tax form references are to Federal form 1040 Schedule C. Complete one Self-Employment Income Calculation for each business owned by the applicant. NJFAP Total for Business 1 (Higher of A or B) (Transfer total of all businesses owned by the patient to Section V, Line 2)
5 SELF-EMPLOYMENT INCOME CALCULATION: BUSINESS 2 3-Month Amount Prior 12 Months (from tax return) Gross Business Deposits Business Expenses Salaries/Wages (Line 26*; excludes amounts paid to self) Benefits (Line 14*) Insurance (Line 15*) Rent (Line 20*) Cost of Goods Sold (Line 4*) Mortgage Interest (Line 16a*) Taxes (Line 23*) Maintenance (Line 21*) Utilities (Line 25*) Supplies (Line 22*) Professional Services (Line 17*) Advertising (Line 8*) Education/Licensing/Certification Bad Debts (Line 9*) Office Expense (Line 18*) Car/Truck Expenses (Line 10*) Other Total Expenses GROSS DEPOSITS (TOTAL EXPENSES) x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 NET PROFIT A B *All tax form references are to Federal form 1040 Schedule C. Complete one Self-Employment Income Calculation for each business owned by the applicant. NJFAP Total for Business 2 (Higher of A or B) (Transfer total of all businesses owned by the patient to Section V, Line 2)
6 SELF-EMPLOYMENT INCOME CALCULATION: BUSINESS 3 3-Month Amount Prior 12 Months (from tax return) Gross Business Deposits Business Expenses Salaries/Wages (Line 26*; excludes amounts paid to self) Benefits (Line 14*) Insurance (Line 15*) Rent (Line 20*) Cost of Goods Sold (Line 4*) Mortgage Interest (Line 16a*) Taxes (Line 23*) Maintenance (Line 21*) Utilities (Line 25*) Supplies (Line 22*) Professional Services (Line 17*) Advertising (Line 8*) Education/Licensing/Certification Bad Debts (Line 9*) Office Expense (Line 18*) Car/Truck Expenses (Line 10*) Other Total Expenses GROSS DEPOSITS (TOTAL EXPENSES) x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 NET PROFIT A B *All tax form references are to Federal form 1040 Schedule C. Complete one Self-Employment Income Calculation for each business owned by the applicant. NJFAP Total for Business 3 (Higher of A or B) (Transfer total of all businesses owned by the patient to Section V, Line 2)
7 SELF-EMPLOYMENT INCOME CALCULATION: BUSINESS 4 3-Month Amount Prior 12 Months (from tax return) Gross Business Deposits Business Expenses Salaries/Wages (Line 26*; excludes amounts paid to self) Benefits (Line 14*) Insurance (Line 15*) Rent (Line 20*) Cost of Goods Sold (Line 4*) Mortgage Interest (Line 16a*) Taxes (Line 23*) Maintenance (Line 21*) Utilities (Line 25*) Supplies (Line 22*) Professional Services (Line 17*) Advertising (Line 8*) Education/Licensing/Certification Bad Debts (Line 9*) Office Expense (Line 18*) Car/Truck Expenses (Line 10*) Other Total Expenses GROSS DEPOSITS (TOTAL EXPENSES) x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 x 4 NET PROFIT A B *All tax form references are to Federal form 1040 Schedule C. Complete one Self-Employment Income Calculation for each business owned by the applicant. NJFAP Total for Business 4 (Higher of A or B) (Transfer total of all businesses owned by the patient to Section V, Line 2)
8 IN-KIND INCOME CALCULATION Room: Fair Market Value of Room (if provided): Calculated Value of Room (if no Fair Market Value is available): Number of Household Members (per Application) Value per Room Value Table Calculated Value of Board: Number of Household Members (per Application) Value per Board Value Table Total In-Kind Income (Transfer to Section V, Line 3): DO NOT COMPLETE THIS PART OF THE FORM IF THE CLIENT RECEIVES EMPLOYMENT INCOME AND/OR UNEARNED INCOME Expense Monthly Amount Expense Monthly Amount Auto Insurance Eye exams & lenses Auto Loan Groceries (food & toiletries)** Auto maintenance & gas Loans Child & elderly care Pharmacy Alimony (paid) Physicians Child support (paid) Rent/mortgage Credit cards Telephone Dental Water, sewer, trash Diapers & baby formula Other expenses (list) **Do not include the value of Food Stamps or WIC Total x 12 months = (Transfer to Section V, Line 4)
City State Zip County. List household members (First/Last) Relationship Date of Birth S.S.N Residency
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