Application For Determination Of Eligibility For Children With Developmental Disabilities Form

Application For Determination Of Eligibility For Children With Developmental Disabilities Form - New Jersey

EPARTMENT OF

HILDREN AND

AMILIES

HRIS

HRISTIE

Governor

, P

.D., L.S.W.

UADAGNO

LLISON

LAKE

Lt. Governor

Commissioner

Division of Children’s System of Care

#1 - Application for Determination of Eligibility for Children with Developmental Disabilities

In accordance with the Revised Statute, State of New Jersey, Section 30:4-25.2, application is being made

to the Commissioner of the Department of Children and Families for a determination of eligibility for

services provided through the Division of Children’s System of Care (CSOC) for:

Name: ________________________________________________________________________

First

Middle

Last

Date of Birth: ________/________/________

By signing this application, I also am declaring that:

1. The Applicant, and/or his or her parent or legal guardian if Applicant is under 18, is a resident of

New Jersey for other than temporary purpose and has expressed an intention to have his or her

primary residence in the State in accordance with N.J.A.C. 10:196

2. This Application and all forms submitted along with it are completed as accurately as possible

3. I understand that I have the opportunity to appeal a determination of ineligibility in accordance

with N.J.A.C. 10:196-5.1, and

4. I understand that if the Applicant is found eligible for CSOC services and requests residential

services, he/she will be required to provide all financial information in accordance with N.J.A.C.

10:46D before residential services will be provided.

This application is being made under R.S. 30:4-25.2 by virtue of the relationship to the Applicant

indicated above:

_____ Parent

_____ Legal Guardian of minor (child)

_____ Court having jurisdiction over a minor

_____ Legal Guardian of the person (adult)

_____ Court of Competent Jurisdiction

_____ Agency with custody of and caring for a minor

Signature ____________________________________________ Date: __________________

Title of Agency or Court representative: ____________________________________________________

Do Not Write Below This Line – for CSOC use only

________ Eligible

__________ Case closed/insufficient information

_________Not Eligible

_____________________________________________________________________________________________

___________________________ ___________________________________ ___________________________

CSOC Representative Signature

Title/Discipline

Date

New Jersey Is An Equal Opportunity Employer

Application For Determination Of Eligibility For Children With Developmental Disabilities Form - New Jersey

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