Form Wfnj-1jx - Cash Assistance/food Stamp/medicaid Application And Registration printable pdf download

WFNJ-1JX (Rev. 12/02) PG.1

CASH ASSISTANCE/FOOD STAMP/MEDICAID APPLICATION AND REGISTRATION

FOR OFFICE USE ONLY

WFNJ/TANF Case Number: ______________________________

IV-D Case ID: ____________________________

WFNJ/GA Case Number: ________________________________

IV-D-Case ID: ____________________________

FS Case: Number:______________________________________

IV-D Case ID:_____________________________

Medicaid Case Number.: ________________________________

IV-D Case ID:_____________________________

APPLICANT: Please print and use a pen to complete this form.

1. Applicant's name:

AST)

(FIRST)

(MI)

(MAIDEN)

2. Date of birth: ____________________________________ Place of birth: ______________________________________________

3. Resident Address: The place where you actually live.

(NUMBER AND STREET OR RFD)

(CITY)

(STATE)

(ZIP CODE)

For Which Program(s) Do You Wish to Apply?

( ) WORK FIRST NEW JERSEY/TANF (Cash Assistance).

You are not able to support yourself and/or your children or the

children who are in your care.

( ) WORK FIRST NEW JERSEY/GA (Cash Assistance).

You are not able to support yourself or your spouse, if applicable.

( ) MEDICAID (Medical Assistance for yourself or your family).

You do not want or are not eligible for money for daily

expenses but you do not have enough money to pay medical bills.

( ) MEDICAL ASSISTANCE ONLY (pending Birth of a Child).

You are pregnant and you do not have enough money to

pay medical bills.

( ) REFUGEE RESETTLEMENT PROGRAM (including MEDICAID).

You have entered the U.S. as a refugee from another

country. Assistance under this program is limited to 8 months from your date of entry into the U.S., as applicable.

( ) EMERGENCY ASSISTANCE.

You lost (or are in danger of losing) your shelter, food, clothing and/or furniture because of a

fire, flood or other emergency.

Do you wish to apply for the Food Stamp Program? YES ( )

NO ( )

You have the right to file an application for food stamps immediately by providing your name, address, signature and date

signed. If you are determined eligible your benefits will be paid from the date of filing. (If you file an application and

provide all the necessary information about your circumstances and are found eligible, you will get food stamps within 30

days of the date the food stamp office receives your application).

Expedited processing for food stamps: If your household (you and the people who live and eat with you) has little or

no income now, you may be able to receive food stamps within 7 days from the date the application is filed provided that

the entire application is completed and submitted within the 7-day period. YOUR ANSWERS TO THE FOLLOWING

QUESTIONS WILL DETERMINE IF YOU QUALIFY FOR THIS SERVICE.

A) Do you (the household) have more than $100.00 in cash, savings, or checking accounts, etc.? YES ( )

NO ( )

B) Will the household receive more than $150.00 in income for this month? YES ( )

NO ( )

C) Are you a migrant or seasonal farmworker household? YES( )

NO ( )

D) Is the amount of your household's combined monthly gross income and liquid resources (cash on hand, checking or

saving accounts, etc.) less than the amount of your household's monthly rent or mortgage and utilities?

YES ( )

NO ( )

SIGNATURE: __________________________________________________

_______________________________

(SIGNATURE OF PERSON INITIATING APPLICATION)

(DATE SIGNED)

Form Wfnj-1jx - Cash Assistance/food Stamp/medicaid Application And Registration

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