N.J. Admin. Code § Tit. 8, ch. 133, app G
Current through Register Vol. 56, No. 11, June 3, 2024
| APPENDIX G | ||
| BUSINESS MANAGER'S FINANCIAL INQUIRY | ||
| Re: _________________________________ | ||
| (Client) | ||
| Dear ________________________________: | ||
| (Interim Assistance Payee) | ||
| Please respond to the following questions and return to me within 5 days of receipt. Payment of room and board may be contingent upon completion of this form. | ||
| To the best of your knowledge, has the above named client received: | YES | NO |
| Supplemental Security Income Payment? | [ ] | [ ] |
| A Social Security benefit? | [ ] | [ ] |
| Any other type of benefit (specify)? ____________ | [ ] | [ ] |
| A Community Medicaid card? | [ ] | [ ] |
| Rental Assistance Program* (State or Federal)? | [ ] | [ ] |
| If your answer is "yes" to any of these questions, please provide the following information: | ||
| Date Payment/Medicaid card was received: __________________ | ||
| Type of Payment: __________________________________________ | ||
| Amount of Check(s): _______________________________________ | ||
| Check(s) Issued to (name): ________________________________ | ||
| * (Rental Assistance either from a Federal or State-funded program (including DMHS), is excluded as available income that would ordinarily replace IA funding. This exclusion is for clients in independent living situations (i.e. clients own home or apartment where clients have a lease and are responsible for expenses such as the rent, utilities, food, furnishings, maintenance, etc.) and where SSI eligibility would normally continue.) | ||
| ___________________________ | ||
| (Business Manager) | ||
| ___________________________ | ||
| (Interim Assistance Payee) | ||
| ___________________________ | ||
| (Client) | ||
| Sample Form | ||
| Distribution: | ||
| Interim Assistance Payee--Original | ||
| Client | ||
| Business Manager | ||
| (Rev. 11/05) | ||
| (Forms--BMFI) | ||
N.J. Admin. Code Tit. 8, ch. 133, app G