Form Jacc 405 - Application For Jersey Assistance For Community Caregiving (Jacc)
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4APPLICATION FOR JERSEY ASSISTANCE FOR COMMUNITY CAREGIVING (J ACC)
DEPARTMENT OF HEALTH AND SENIOR SERVICES (DHSS)- DIVISION OF AGING AND COMMUNITY SERVICES
1.
LAST NAME
2.
MAIDEN NAME
3.
FIRST NAME
4.
MI
5.
SEX
6.
DOB
7.
STREET ADDRESS
8.
CITY
9.
ST
10. ZIPCODE
11. COUNTY
12. SUBMIT 1
PROOF OF
RESIDENCE
13. ARE YOU A FULL-TIME
14. IF NOT, EXPLAIN
RESIDENT OF NEW JERSEY?
YEs
No
15. SOCIAL SECURITY
#
16. SPOUSE'S NAME
&
17. ARE YOU A UNITED
18. IF NO, SUBMIT PROOF
SOCIAL SECURITY
#
STATES CITIZEN?
OF QUALIFIED ALIEN
STATUS
YES
No
19. DO YOU HAVE/ HAVE
20. IF YES; WHATIS/WAS
21. ARE YOU 60 YEARS OF
22. SUBMIT 1 PROOF OF AGE
YOU HAD A PAAD
YOUR PAAD ELIGIBILITY
AGE OR OLDER?
CARD?
NUMBER?
YEs
No
YES
No
23. MARITAL STATUs:
24. HAs THIS CHANGED IN THE
25. DID YOU AND/OR YOUR
26. IF YES, SUBMIT SIGNED
0
SINGLE
PAST YEAR?
YES
NO
SPOUSE FILE A
COPIES ALONG WITH
0
DIVORCED
FEDERAL, STATE, OR
ANY SCHEDULES
0
SEPARATED
IF so, WHEN?
CITY INCOME TAX
0
MARRIED
RETURN LAST YEAR?
0
WIDOWED
YEs
No
27. Do YOU OWN ANY REAL
28. IF YES, DESCRIBE, GIVE LOCATION AND ESTIMATED EQUITY VALUE
ESTATE OTHER THAN YOUR
HOME?
YEs
No
29. Do YOU HAVE HEALTH
30. IF YES, IDENTIFY THE PLAN OR COMPANY
31. PLEASE INDICATE IF THIS
INSURANCE COVERAGE IN
HEALTH INSURANCE IS:
ADDITION TO MEDICARE?
0
MAJOR MEDICAL
YEs
No
0
MEDICARE SUPPLEMENT
32. IF PROVIDED THROUGH AN EMPLOYER, PLEASE IDENTIFY THE EMPLOYER OR UNION.
0
OTHER:
33. THE AMOUNT Of YOUR MOST
34.
THE AMOUNT Of YOUR SPOUSE'S
RECENT SOCIAL SECURITY CHECK:
MOST RECENT SOCIAL SECURITY CHECK:
35. DO YOU OR YOUR
36. I f YES, LIST THE NAME AND ADDRESS OF THE COMPANY, EMPLOYER, OR UNION.
SPOUSE RECEIVE A
PENSION OR SALARY?
YEs
No
J ACC 405 (REV.8/00)
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