New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 91 - ORGANIZATION AND GENERAL POLICY PROVISIONS OF THE COMMISSION FOR THE BLIND AND VISUALLY IMPAIRED › Subchapter 3 - FINANCIAL STANDARD › Section 10:91-3.1 - Financial need standard and survey

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The financial
				need standard is a test which shall be used to determine a client's ability to
				pay for certain services. For those clients who qualify, the Commission shall
				provide the cost of these services. For clients who do not qualify, the
				standard establishes the level of their responsibility toward the cost of those
				services. The Financial Survey Form and the Financial Participation Worksheet
				are the documents used to gather and analyze information needed to determine
				financial eligibility. The exception is college tuition assistance where the
				Commission utilizes the standard forms required by many college applicants for
				financial aid.
(b) The following
				concerns the Financial Survey Form:
1. A
				financial survey form shall be completed for each new and readmitted client at
				the time of the first authorization for any services subject to financial need.
				The client supplies the information and the primary caseworker completes the
				form.
2. Survey forms shall not be
				mailed to clients for completion.
3. Income may be verified by pay stubs, or
				check stubs from pensions or benefits. The caseworker may request the previous
				year's income tax forms to identify any additional income or to verify the
				number of individuals reported as dependent on family income. Dependent refers
				to the total number of individuals dependent on family income, consistent with
				what is reported on IRS income tax forms.
4. A home occupied by a client as a residence
				is not counted as a resource. Income from property shall be counted after
				deducting the cost of operation and maintenance from the gross income
				received.
5. Existing insurance
				policies shall not be counted as a resource but clients are advised to check to
				see whether they are eligible for disability payments. Disability payments
				received shall be counted as income at the time they are received.
6. Personal effects such as personal apparel,
				jewelry, and household effects shall not be counted as a resource.
7. The client or parents shall be told that
				the financial survey form and financial participation worksheet shall become
				part of the client's confidential case record.
8. Client or parent refusal to provide
				financial information or to sign the financial survey form shall be noted in
				the client's case record.
9. A copy
				of the completed survey shall be offered to the client, and mailed if
				requested.
10. The Financial Survey
				Form is as follows:
FINANCIAL SURVEY FORM
1. Client Name and SS#
.....................................................................
2. Counselor and date
.....................................................................
ANNUAL FAMILY INCOME:
3. Amount of Gross Pay of Client (Before
				Deductions)
.....................................................................
4. Amount of Husband/Father Gross
				Pay (If applicable)
.....................................................................
5. Amount of Wife/Mother Gross Pay
				(If applicable)
.....................................................................
6. Amount of Guardian and/or other
				contributing family member Gross Pay
.....................................................................
In items 7 through 16, list the amount, how often paid and
				  when benefits will cease:
7. Unemployment/Temporary Disability
				Insurance
.....................................................................
8. Worker's Compensation
.....................................................................
9. VA Pension
.....................................................................
10. Supplemental Security Income
.....................................................................
11. Social Security Retirement or
				Disability
.....................................................................
12. Welfare
.....................................................................
13. Income from property
....................................................................
14. Alimony or child support
.....................................................................
15. Other income (specify)
.....................................................................
16. GROSS TOTAL CASH INCOME FROM
				ALL SOURCES (TOTAL LINES 3-15)
.....................................................................
17. Total Number of Persons
				Depending on Family Income, Including Client
.....................................................................
MEDICAL INSURANCE: (Check appropriate Space) ... Blue Cross;
				  ... Blue Shield; ... Rider J or Major Medical; ... Medicare-Part A ... or Part
				  B ...; ... Medicaid; ... Other; Specify ...
The information given above is a true statement of my
				  financial condition.
Signature of Client/Guardian
.....................................................................
A review of the information on this form on the following
				  date(s) indicates that there had not been a substantial change in the client's
				  financial situation:
Date No. 1:
.....................................................................
Date No. 2:
.....................................................................
Date No. 3:
.....................................................................
Date No. 4:
.....................................................................