First Name: Last Name: MIS #: Person Completing Form: Phone: Email: Current Residence/Contact Street: City: State: Zip: County of Residence: Assigned Worker Contact Information (There must be a Support Coordinator Assigned before sending) Assigned Worker Type: Support Coordination (SC) : DDD Case Management: SC Agency: SC Name: SC Phone: SC Email: DDD Contact Name: DDD Contact Phone: DDD Contact Email: Eligibility Information NJCAT Score: NJCAT Date: Medicaid Eligible: Yes No What waiver will individual receive services through Supports Program: (Select One)?: CCW: Waiver Services Currently Being Received Current Housing Information Currently Living Arrangement: Is there Family Involvement: Current Payee: Guardianship Status: Yes No Self None Other: Guardian (Please Identify) Housing Needs Please describe what about the situation deems it as having housing instability: Number of Bedrooms Requested (Please note that more than is only permitted in very narrow circumstances): Housing Arrangement Being Already in an Apartment and Looking for New Apartment Sought (Select only one): will remain there, at least until (Support Coordinator must submit the end of current lease (Case this form) Manager may submit this form) Office Use Only Approved By: Denied By: Number of Bedrooms Approved: Date: Date: Reason: Sent to Division Housing Subsidy Program Unit on:
First Name: Last Name: MIS #: Person Completing Form: Phone: Email: Current Residence/Contact Street: City: State: Zip: County of Residence: Assigned Worker Contact Information (There must be a Support Coordinator Assigned before sending) Assigned Worker Type: Support Coordination (SC) : DDD Case Management: SC Agency: SC Name: SC Phone: SC Email: DDD Contact Name: DDD Contact Phone: DDD Contact Email: Eligibility Information NJCAT Score: NJCAT Date: Medicaid Eligible: Yes No What waiver will individual receive services through (Select One)?: Supports Program: CCW: Waiver Services Currently Being Received Current Housing Information Currently Living Arrangement: Is there Family Involvement: Yes No Current Payee: Self Other: Guardianship Status: None Guardian (Please Identify) Housing Needs Please describe what about the situation deems it as having housing instability: Number of Bedrooms Requested (Please note that more than is only permitted in very narrow circumstances): Housing Arrangement Being Sought (Select only one): Already in an Apartment and will remain there, at least until the end of current lease (Case Manager may submit this form) Looking for New Apartment (Support Coordinator must submit this form) Office Use Only Approved By: Number of Bedrooms Approved: Date: Sent to Division Housing Subsidy Program Unit on: Denied By: Date: Reason:
HousingVoucherEligibilityDeterminationForm-Attachment1.docx