N.J. Admin. Code § Tit. 8, ch. 133, app A
Current through Register Vol. 56, No. 23, December 2, 2024
| INTERIM ASSISTANCE STATEMENT | |
| I have been made aware of the Interim Assistance Program and its | |
| requirements, and understand my rights and responsibilities as a recipient | |
| of Interim Assistance. | |
| I am _______ am not _______ interested in applying for Interim Assistance. | |
| Signature: ____________________________ | |
| Witness: ____________________________ | |
| Date: _______________________________ | |
| Sample Form | |
| Distribution: | |
| Financial Coordinator (original) | |
| Client | FORM MH-30 |
| Hospital Social Worker | (Rev. 1/90) |
N.J. Admin. Code Tit. 8, ch. 133, app A