The NJ FamilyCare Eligibility Determining Agency (EDA) verifies your application information. If the EDA cannot electronically verify your personal information, you may be asked to provide proof of identity, age, citizenship and/or marital status. The EDA may also ask for documentation that will prove what you own, how much income you receive, where this income comes from, and how much you spend on living expenses. During the eligibility determination process, the information you provided will be verified. If there is missing information, you will receive a letter. Failure to respond timely to these letters may delay application processing or cause denial of your application.

Income You Receive Income can come from different sources such as a paycheck, pension, or interest from an investment account. Listed below are examples that can prove your income.

❑ Income Statement from Employer/ Pay Stubs 

❑ Pension Information 

❑ Unemployment Benefit Statement 

❑ Child Support Order 

❑ Self-Employment Tax Return 

❑ VA Explanation of Benefits 

❑ Interest 

❑ Proof of Rental/Royalty Income 

❑ Social Security Award Letter 

❑ Retirement Account Statement 

❑ Dividends 

❑ Income from Trust Funds 

❑ Annuity Payments 

❑ Workman’s Compensation/Disability 

❑ SSI Payments 

❑ Cash on Hand 

❑ Bank Accounts 

❑ Deeds to all Property Owned 

❑ Certificates of Deposit (CDs) 

❑ Promissory Notes 

❑ Annuities 

❑ Mortgages 

❑ Equipment/Inventory 

❑ Automobile/Registrations 

❑ Other Vehicles (Boat, Trailer, etc.) 

❑ Holiday/Vacation Club Accounts 

❑ Property Tax Statements 

❑ All Life Insurance Policies 

❑ All Trusts or other Holding Instruments 

❑ Special Needs Trusts 

❑ ABLE Accounts 

❑ Retirement Accounts (403B) 

❑ Individual Retirement Accounts (IRAs) 

❑ Business/Real Estate Partnership Papers 

❑ Burial Accounts/Funeral Trusts 

❑ Credit Union Accounts 

❑ Stocks or Bonds 

❑ Deed to Burial Plots 

❑ Land/Mineral Rights 

❑ Keogh Accounts (401K) 

❑ Contracts 

❑ Mobile Home 

What You Own Ownership is not limited to homes and automobiles - it can include cash values of life insurance policies or annuities, trust funds, and many other things. Provide documentation with your application of any of the following items that you own or owned during the last five years: 1 Your Other Documents

❑ Copy of Health Insurance Card(s) - front and back 

❑ Designated Authorized Representative Form 

❑ Copy of Any Settlements 

❑ Power of Attorney 

❑ Guardianship Applicants in need of Long Term Services and Supports (LTSS) may also be required to submit the following information: Your Living Expenses How much money do you (and your spouse) need to live in the community each month? 

The expense of maintaining your house or renting an apartment can account for a large part of your monthly income. 

The following are examples of expenses to include with your application: 

❑ Rent Payments 

❑ Telephone Bills 

❑ Water/Sewer Bills 

❑ Health Insurance Bills 

❑ Mortgage Statements

❑ Gas/Oil Bills 

❑ Real Estate Tax Bills 

❑ Electric Bills 

❑ Renter/Home Owner Insurance Five-Year Lookback on Resources One bank statement per quarter from each of the last 5 years may be submitted along with your application for all financial accounts (open or closed) with the applicant’s name on it.* Examples of accounts and transactions include: 

❑ Checking Accounts 

❑ Money Market Accounts

❑ Savings Accounts 

❑ Any Gift/Transfers (money or real estate)

❑ Credit Union Shares/Accounts 

❑ Investment Accounts 

❑ Life Insurance Policies * You may be asked to provide all statements from the past 5 years, and additional information related to these funds, if the EDA requires more information. Qualified Income Trust (QIT) A QIT is a written trust agreement used to establish a dedicated bank account. Clinically eligible LTSS applicants with higher incomes use QITs to financially qualify for LTSS. The monthly income amount that is over the monetary limit for eligibility is deposited in a QIT account. The money in the QIT account will not be counted as income when Medicaid financial eligibility is determined. However, all funds in a QIT must be spent each month as determined by the EDA. When applicable, provide the EDA with the ABD application along with the following documents in order to have the application processed: 

❑ Qualified Income Trust Document A simple, easy-to-follow template and more information for establishing this Trust may be found at: http://www.state.nj.us/humanservices/dmahs/clients/mtrusts.html 

❑ Proof of funding the QIT is required for the month eligibility starts. This may be a deposit slip or bank statement showing the income is being deposited monthly. An individual’s own Social Security income and/or pension income can be deposited into the QIT in the month that it is received. An individual can direct all or some of their income to the QIT but all the income from any one source (e.g. the entire monthly amount of a pension check) must be deposited into the QIT.