NJ SAVE instructions

Transcript

1 Instructions for Completing the Division of Aging Services Online NJ SAVE Application The Online NJ SAVE Application affords individuals the opportunity to apply for benefit assistance for :  Medicare Savings programs (SLMB or SLMB QI1) , that pay Medicare Part B premium payments  Prescription assistance programs (PAAD or Senior Gold)  Utility assistance programs (Lifeline Utility Credit Program or Tenants Lifeline Assistance Program ) , Univ ersal Service Fund (USF), Low - Income Home Energy Assistance Program (L i HEAP)  Hearing Aid Assistance for the Aged and Disabled (HAAAD) ,  Medicare Part D premium payments for , certain Part D plans if PAAD eligible AP) Supplemental Nutrition Assistance Program (SN  Voter registration information  Many other programs use the acceptable PAAD/Lifeline eligibility determination to give even more benefits:  Motor Vehicle registration discount cost pet spay/neuter  Low -  Property Tax Freeze These instructions are primarily intended to assist third parties (e.g. powers of attorney, case workers, legislative officials, area agencies on aging, etc.) with the proper completion of the Online NJ SAVE application. The instructions are equally benef icial to applicants if they desire to be more informed while completing the An application Online NJ SAVE application. is needed for each person ; however, married couples can choose to apply on the same application. rmation on each section, including: The instructions provide detailed info A brief explanation of how each question relates to the determination of eligibility and  why the question has been included on this application.  Step by step instructions for completing each question. INSTRUCTIONS NJ SAVE 1 OCT 2018

2 Welcome Section: can begin a new application or complete a saved application. The applicant Instructions: For a new application, click Start New Application .  For a saved application, click Resume Existing Application .  Section: Getting Started questions to determine if applicant is eligible to apply. Basic screening Instructions:  NOTE: The applicant must c lick to Yes or No for the questions provided. the circles next 1 is N o, a yellow box will appear  Question 1 / State Residency – If the answer to question the bottom informing the applicant that they may not be eligible at .  Question 2 / Age 65 or older – If the answer to question 2 is No, a new question will appear.  Question 3 / Under 64 with Social Security Disability – If the answer to question 3 is No, a ye llow box will appear at the bottom informing the applicant that he or she may not be eligible . The applicant will be directed to the Division website to review the program eligibility requirements.  Continue to Application Click Section: Program Descri ption . Program descriptions list the benefits and eligibility requirements for each program Instructions:  NOTE: To access the program information, the applicant can click on the shaded section headers. For further details about each program, the applicant can click on the to go to the Division website. information in each section or the word here Click Continue to Application  INSTRUCTIONS NJ SAVE 2 OCT 2018

3 Section: Language Assistance rovide s Language assistance p services to people with disabilities to communicate and free language services to people whose primary language is not English. Instructions:  NOTE: T he applicant can click on the Nondiscrim in ation Statement to download the statement page.  Click Continu e to Application Section: Process and Checklist This page lists important features and information of the online application. Including the type of documents that will be helpful in completing the application and a guide for the symbols found on the application. For instance, on the application you will see a * (red asterisk, because I am in review it will not let me use red) next to many fields. This indicates ed to move to t a required field that the applicant will need to answer before being allow he next section. Instructions:  NOTE: The applicant can click on Print this page to download page for reference while completing the application.  Click Continue to Application Section: Privacy Policy will keep This page i nforms the applicant that the Division private as his or her information required by law. The Division will also utilize various databases from other states and federal agencies to verify information. Instructions: NOTE: The applicant must click on  Agree or Disagree . If disagree, the applicant will not The applicant can obtain further information be able to complete the online application. on the Department of Human Services Privacy Practices in either English or Spanish by clicking on Spanish . or English INSTRUCTIONS NJ SAVE 3 OCT 2018

4 Section: Registration an account with the Division. This account will allow applicant creat e section asks the to This lete the application in multiple sessions if they prefer . the applicant the opportunity to comp Creating an account is recommended, but optional. Instructions: NOTE: The applicant can create an account by entering the below information and  Send Confirmation Email clicking . If the applicant does not have an email address, or do es not wish to register, click File Application Without Registering . If the applicant is completing the application as a guest user, a warning will appear giving them one last chance to register . If the applicant wishes to continue, c lick File As G uest . As a guest user, the applicant must complete the entire application at this time as the information cannot be saved. Please note, the application will time out after 15 minutes of inactivity and all information entered will be lost.  Email – Type desired email address. Type first name.  First Name – Type middl – Middle Name e name.   – Type last name. Last Name Section: Login / Create Password (only if registering) The applicant will need to create a pas sword for registration. A pplicants that are completing the application as a guest user will not see this screen. Instructions:  the applicant will need to access their email to get the link to NOTE: In order to register , the registration page. The email link will take them to a page to create a password.  Password / Confirm Password – Type desired password in each field.  The applicant must click in the Captcha box next to I’m not a robot. Follow the instructions for the pictures that appear in the box. To select a different task, click the refresh arrow in the bottom left corner be low the pictures. After completing the task, click . This process may have to be repeated. Once the applicant has received a Save Progress . egistration Complete R TCHA task is completed. Click green check mark, the CAP INSTRUCTIONS NJ SAVE 4 OCT 2018

5 Section: Sign In pplicants that are completing the application as a guest A The applicant will need to sign in. user will not see this screen. Instructions: Username – Type the email address used in registration.  – Type password used in registration. Password  Section: Contact Details / Home Address This section asks the applicant to enter their physical place of residence. This will verify that the applicant is a resident of the State of New Jersey. Instructions:  Type the applicant’s actual physical street address (Number and Street ) in line 1, type apartment or floor number in line 2 , if applicable, and city. Select the state abbreviation from the drop down box and type the zip code and  NOTE: P.O. Box addresses are not acceptable as a principal place of residence. If using a P.O. Box, enter it in the “Mailing Address” in the following section. The applicant must submit two proofs of residence.  NOTE: Examples of acceptable proofs , are available in the attachments section. Typically with name and any current document address, like utility, cell phone, or medical bills are acceptable. NOTE: SEASONAL OR TEMPORARY RESIDENCE IN NEW J ERSEY OF WHATEVER DURATION, DOES NOT QUALIFY AS A PRINCIPAL PLACE OF RESIDENCE. Section: Contact Details / Mailing Address This section asks the applicant to enter their mailing address, if different from his or her place of residence. Instructions:  If the home and mailing address are the same, the applicant must click the first box and the section will be re moved. type the applicant’s mailing address (Number does use a mailing address  If the applicant , and Street) in line 1, type apartment or floor number in line 2, if applicable, and city. Select the state abbreviation from the drop down box and type the zip code.  If using a Power of Attorney (POA) , please enter the Power of Attorney ’s mailing address paperwork and s ubmit a copy of the Power of Attorney . INSTRUCTIONS NJ SAVE 5 OCT 2018

6 Section: Contact Details / Phone Numbers and Email applicant to provide a , in the event This section asks the phone number and email address questions about the application arise . The information in this section is recommended, but optional. Instructions: Type the phone numbers and email address in the fields provided. Primary # should be  phone number that you can most likely be reached at. the Section: Contact Details / Preferred Contact he applicant prefers that someone else be contacted in case of If t questions about the s application and a new set of field will appear. If n o is selected, t he section will be , select yes removed and the applicant must c lick Save and Next . Instructions:  select the Select the best option to describe the contact person – The applicant must option that most accurately describes the contact person from the drop down list. the contact person’s Type – First Name first name.   Last Name – Type the contact person’s last name.  Mailing Address – Type the contact person’s mailing address (Number, Street , a nd line 1 apartment or floor number ) in , and city. Select the state abbreviation from the drop down box and type the zip code.  Phone Number – Type the contact person’s phone number.  Save and Next Click  Those applicants that are completing the application as a guest user have to NOTE: complete the Captcha task. R egistered users will move on to the next section. The applicant must click in the Captcha box next to I’m not a robot. Follow the instructions for the pictures that appear in the box. To select a different task, click the refresh arrow in the bottom left corner below the pictures. After completing the task, click e the applicant has received a . This process may have to be repeated. Onc Save Progress green check mark, the CAPTCHA task is completed.  Save and Next Click INSTRUCTIONS NJ SAVE 6 OCT 2018

7 Section : Household / Household Details asks the applicant to provide personal information regarding him or herself, as This section well as a spouse, if married. Instructions: NOTE: The applicant must enter his or her name exactly the way it appears on records or  documents that he or she receives from Medicare. – Type first name. First Name  – Middle Name  Type middle name.  Last Name – Type last name.  Suffix (Jr., Sr., II, III, etc.) – Type the suffix, if applicable.  Date of Birth – Type date of birth using a MM/DD/YYYY format .  Gender – Select between Male or F emale. – The applicant must Marital Status select the option that most accurately describes his or  her marital status from the drop down list. If married is selected, a new section will appear for the spouse’s information to be  NOTE: completed. Repeat this process for spouse’s information. If separated, an affidavit of sepa ration form will be provided that will need to be completed by the applicant.  List your Social Security Number – Type the applicant’s Social Security number. If the applicant does not have a social security number or does not wish to provide it at this time, he or she must click the box next to Not Given . A message will appear informing the applicant that they ma y have to provide the SSN at a later time and not providing it can cause processing delays. Living Arrangement – The applicant must select the option that most accurately describes  The applicant is no t required to his or her living arrangement from the drop down list. choose an o ption from both drop down lists; only the option that best describes their living arrangement.  Has Marital Status changed in last year – Select between Yes or No. If yes is selected, a new field will appear for the applicant to ty pe the date the marital status changed using a MM/DD/YYYY format .  Is Spouse applying for benefits – Select between Yes or No. Click Save and Next  INSTRUCTIONS NJ SAVE 7 OCT 2018

8 Section: Member Information – Demographics is used to collect statistics for demographics only. They will not affect program This section eligibility. Instructions: – Select between Yes or No.  Are you a veteran Citizenship/Immigration Status – The applicant must select the option that most  r her status from the drop down list. accurately his o Ethnicity select the option that most accurately his or her status – The applicant must  from the drop down list.  – The applicant must select the option that most accurately his or her status from the Race drop down list.  NOTE: If married, and spouse is applying, this process will need to be repeated for spouse’s section.  Click Save and Next Section: Income Details – Monthly and Annual information about the most common This section asks the applicant to provide sources of even if , Please note income. This information will be used to determine income eligibility. only the applicant is applying, if married, this section will be repeated for the spouse. Please do not combine income. Instructions: Did you file a  – Select between Yes or No. Federal/State income tax return last year  Do not have monthly or a nnual income – If the applicant does not have monthly or annual income, he or she must check the first box and the section will be removed .  Indicate Type of Monthly Income / Total current Monthly amount – Select the type of income from the drop box on the left and then type the monthly amount in the field on the right. type of –  Indicate Type of Annual Income / Total current Annual amount Select the income from the drop box on the left and then type the annual amount in the field on the right .  NOTE: This section is broken into monthly and annual to make it easier to enter income types that are the same monthly, like social security or pension , and then to estimate annual amounts of income such a s interest.  Add Monthly NOTE: If more income types exist, the applicant can click on the blue If the or button to create a ne w line and repeat the process. Add Annual Income Income applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. INSTRUCTIONS NJ SAVE 8 OCT 2018

9 Section: Income Details – Rental Income asks the applicant to provide information about Please note that rental income. This section if the applicant is married, his or her own income should be listed here. Do not combine spouse’s income with the applicant’s income. He or she will be asked to complete the spouse’s income on the next page. Instructions: receive –  Do not receive rental income rental income, he or she If the applicant does not must check the first box.  Enter Rental Income Information – If the applicant does receive rental income, he or she has the choice to enter the information now or wait until later in the applica tion process. If the applicant clicks the box, new fields will appear. Rental Address  – If the rental address is the applicant’s home address / Home Address click the first box and the field will be removed. If the addresses are different, t ype the r l address (Number, Street, apartment or floor number , city, state and zip code) . enta Type the amount of rental listed on the last tax Amount shown on income tax return –  return. . Type the amount of monthly gross rent Current Monthly Gross Rent –  annual Annual Gros s Rent – Type the amount of  gross rent .  Enter the year for reporting expenses – Type the year. Type the expense in the field on the left and Provide rental expenses and deductions –  then type the deduction amount in the field on the right. the applicant entered will be calculated as the Total Deductible  NOTE: The amount (s) Documentation of expenses may Expenses and Net Rental Income after the page is saved. be requested.  button to nse Add NOTE: If more expenses exist, the applicant can click on the blue Expe create a new line and repeat the process. If the applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. INSTRUCTIONS NJ SAVE 9 OCT 2018

10 Section: Income Details – Work Income information about Please note that if asks the applicant to provide work income. This section the applicant is married, his or her own income should be listed here. Do not combine spouse’s income with the applicant’s income. He or she will be asked to complete the s pouse’s income on the next page. Instructions: Do not receive work income – If the applicant does not receive work income, he or she  must check the first box. Indicate Type of Monthly Income / Total current Monthly amount –  Select the type of m the drop box on the left and then type the monthly amount in the field on the income fro right.  The amount (s ) NOTE: the applicant entered will be calcul ated as the Total Earned Income after saving the page.  Expect a Net Self Employment Loss – The applicant must check the box if there is an expected loss of self employment income . -  he or she worked ast two years – T he applicant must check the box if Worked in the l within the last two years . the box if – he applicant must check T  Recently stopped working or plan to stop working he or she has stopped or plans to stop working . Income decreased in last two years  T he applicant must select between Yes or No if his or – hers work income has decreased in the last two years.  NOTE: If more income types exist, the applicant c an click on the blue Add Income button to create a new line and repeat the process. If the applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. Changes – Section: Income Details This section information about irregular income. Please note asks the applicant to provide that if the applicant is married, his or her own income should be listed here. Do not combine spouse’s income with the applicant’s income. He or she will be asked to complete the spouse’s income on the next page. Instructions:  Monthly income does not change from month to month – If the applicant’s income does not change, he or she must check the first box.  Total Income this year / Total Estimated Income next yea r – If the applicant’s income amount for this year in the field income from on the does change, he or she must type the left and . type the income amount estimated for next year in the field on the right Save and Next Click  INSTRUCTIONS NJ SAVE 10 OCT 2018

11 Section: Medicare Details This information is used to coordinate benefits with other State and Federal benefit programs. Please note that if both applicant and spouse are applying, this section will be followed by the spouse’s information. Instructions: Do not have Medicare Coverage –  If the applicant does not have Medicare coverage, he or she must check the first box. Enter Medicare or Railroad Retirement Number  The applicant must type his or her – Medicare Claim number or Railroad R etirement number in this field.  NOTE: The applicant must type Medicare Claim number exactly as shown on the applicant’s and spouse’s (if applicable) Medicare Card(s). Indicate Medicare Coverage / Effective Date –  Select the Medicare coverage type of from the drop box on the left and then enter the effective dates in the field on the right using a MM/DD/YYYY format.  NOTE: To add additional Medicare coverage, the applicant can click on the blue Add Medicare Cover button to create a new line and repeat the process. If the applicant age made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line.  Click Save and Next Section: Medicare Part D Enrollment Assistance Form T his information is use Medicare Part D prescription plans . d to coordinate benefits with Please note that if both applicant and spouse are applying, this section will be followed by the spouse’s information. Instructions:  Select Medicare Part - D Enrollment – T he applicant must select which of the e nrollment options is preferred.  Prescription Drugs – Select between Yes or No.  List Pharmacies used – The applicant must type the pharmacy he or she uses.  Submit Drug list later – The applicant can check if they wish to submit a list of the drugs they use following this process.  List Drug Name / Strength / Quantity per month – The applicant must type the drug name in the field on the left, the strength of the drug in the middle field and the prescribed monthly quantity in the field on the right. To add additional medications , the applicant can click on the blue Add Drugs Details button to create a new line and repeat the process. If the applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. Save and Next Click  INSTRUCTIONS NJ SAVE 11 OCT 2018

12 Section: Health Insurance applicant and the applicant’s spouse (if married) to provide information This section asks the additional health insurance plans so that all prescription benefits may be regarding coordinated properly. Instructions: Do not have Health Insurance coverage – If the applicant does not have Health Insurance  coverage, he or she must check the first box. Health Insurance Organization – The Health Insurance Company applicant must type the  he or she is enrolled in.  Cover Prescription Drugs – Select between Yes or No.  Prescription Co - – The applicant must type the prescription co - pay amount s . pay Amount  Coverage through a retiree or employer group plan – Select between Yes or No. name of employer or union. The applicant must type the –  Employer or Union Name  – The applicant must type the Telephone Number Health Insurance Company’s telephone . number  Address – The applicant must type the Health Insurance Company’s address (Number, Street, apartment or floor number , city, state and zip code). – Retiree/Union Health care plan has creditable coverage Select between Yes or No.  coverage exists, the applicant can click on the blue  NOTE: If additional Health Insurance button to create a new line and repeat the process. If the Coverage Health Insurance Add applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the lin e.  Save and Next Click INSTRUCTIONS NJ SAVE 12 OCT 2018

13 Section: Resource Details – Bank Accounts , the appli (if married) provide a more detailed section cant and the applicant’s spouse In this in check ing accounts, savings accounts and ac counting of their liquid assets certificates of . Please note that if the applicant is married, both his and his spouse’s information deposit should be entered. Assets are NOT counted when determining PAAD, Senior Gold, Lifeline or HAAAD NOTE: eligibility. Instructions:  Enter the number of relatives who live with the applicant and for whom the applicant . provides at least half the support  – If the applicant does not have any bank accounts, he or she Do not have bank account must check the first box.  – The applicant m ust type in the kind of Account Type account he or she owns; for example checking or savings.  Financial Institution – The applicant must type name of the bank .  Account Number – The applicant must type the account number . .  Account Balance – The applicant must type the current balance ered will be calculated as the t the applicant ent otal Bank Accounts  (s) NOTE: The amount after the page is saved. I Add f more accounts exist, the applicant can click on the blue ss. If the applicant made a Bank Account button to create a new line and repeat the proce mistake or wishes to delete a created line, click on the trash can icon to the right of the line. Section: Resource Details – Investments In this section , the applicant and the applicant’s spouse (if married) provide a more detailed accounting of their liquid assets in stocks, bonds, mutual funds, money market funds, individual retirement accounts (IRA), annuities, trusts, savings bonds, treasury bills or treasury bonds. Instructions:  Investment Type – The applicant must type the name of the type of investment .  Financial Institution – The applicant must type name of the financial company . The applicant must type the  – Account Number account number .  Market Value – The applicant must type the current market value .  NOTE: The amount (s) the applicant ent ered will be calculated as the t otal Investments exist, the applicant can click on the blue investments Also, if more after the page is saved. If the applicant made button to create a new line and repeat the process. Investment Add a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. INSTRUCTIONS NJ SAVE 13 OCT 2018

14 Section: Resource Details – Vehicles section applicant and the applicant’s spouse (if married) to provide details on asks the This s owned, and if the vehicle is used by the applicant or any member of the vehicle any transportation to medical care. applicant’s household for transportation to work or for NOTE: source. Medicare Savings Programs count some vehicles as a re Instructions: Owner’s Name  The applicant must type the name of the owner. –  Year/Make – The applicant must type the year and make of vehicle .  – The applicant must type the model and style of vehicle . Model/Style  Amount Owed – The applicant must type any amount owed on the vehicle .  Current Value – The applicant must type the current value of the vehicle .  Primary Use – T he applicant must select between Medical or Work transportation.  NOTE: The amount (s) the applicant ent ered will otal be calculated as the t Vehicles after the page is saved. button to I f more vehicles exist, the applicant can click on the blue Add Vehicle  NOTE: create a new line and repeat the process. If the applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. – Other Cash Section: Resource Details (if married) to specify if he or she This section asks the applicant and the applicant’s spouse any cash at home or anywhere else that is not in an account. has Instructions:  Do not have any other cash – If the applicant and the applicant’s spouse do not have any other cash, he or she must check the first box. – The applicant must type the amount of cash .  Enter Amount Section: Resource Details – Real Estate This section asks the applicant and the applicant’s spouse (if married) to specify if he or she own rea l estate other than his or her home. s any Instructions:  Do not have any real estate – If the applicant does not have any other real estate, he or she must check the first box. . the value of other real estate The applicant must type – Enter Amount  INSTRUCTIONS NJ SAVE 14 OCT 2018

15 Section: Resource Details Valuables – (if married) This section asks the applicant and the applicant’s spouse to provide details on any valuable personal property owned (e.g. jewelry, coin/stamp collections, furs, recreational as vehicles, boats, motorcycles, etc.). NOTE: DO NOT include w edding or engagement rings NOT these are counted. Instructions: valuables  Do not have any have any – If the applicant and the applicant’s spouse do valuables , he or she must check the first box. any valuables  Enter Amount – The applicant must type the value of . Section: Resource Details – Additional Questions This section asks the to specify if any of the applicant and the applicant’s spouse (if married) resources previously listed will be used for funeral or burial expenses . The section also asks ted onto a applicant to indicate if any income is d eposi and the applicant’s spouse (if married) pre - paid debit card rather than a bank account. Instructions: Select between Yes or No. –  Intend to use resources for funeral or burial expenses The applicant must – paid debit card  Social Security or other income deposited onto pre - they have a pre check if - paid debit card . Save and Next Click  INSTRUCTIONS NJ SAVE 15 OCT 2018

16 Section: Resource Details – Life Insurance to provide details on This section asks the applicant and the applicant’s spouse (if married) life insurance policies owned . any The section also requests the value of the policies. Cash surrender value is the dollar amount that would be received if the policy was turned in for Please note that if the applicant is married, his or her own life insurance cash today. life insurance information with should be listed here. Do not combine spouse’s information life insurance information the applicant’s. He or she will be asked to complete the spouse’s on the next page. Instructions:  Do not have life insurance – If the applicant does not have life insurance, he or she must check the first box.  Owner – The applicant must type the name of the owner of the policy.  Insured – The applicant must type the name of the insured .  Insurance Company – The applicant must type the name of the insurance company . – The applicant must type the policy number .  Policy Number policy . Face Value – The applicant must type the current face value of the   Cash Surrender Value – The applicant must type the current cash surrender value of the policy . T – select between Whole Life or Term Life. he applicant must  Type – Term Duration  T he applicant must type the length of the Term policy, if applicable. NOTE: . spouse If married, this process will be repeated for the  Life Insurance Add es exist, the applicant can click on the blue  NOTE: polici If more button to create a new line and repeat the process. If the applicant made a mistake or wishes to delete a created line, click on the trash can icon to the right of the line. INSTRUCTIONS NJ SAVE 16 OCT 2018

17 Section: Resource Details – Trust Details to provide information This section asks the applicant and the applicant’s spouse (if married) owned . regarding trusts Instructions: Do not have trusts – If the applicant does not have trusts , he or she must check the first  box. Type of Trust –  select between testamentary, special needs or a The applicant must . qualified income trust The applicant must Trust funded by –  select from the drop down list. tax  – The applicant must type the Tax ID id of the trust .  Date Trust was initially funded – The applicant must type the date trust was initially funded using a MM/DD/YYYY format .  Grantor The applicant must type the name of the grantor . –  Trustee – The applicant must type the name of the trustee . – Beneficiary . the name of the beneficiary The applicant must type   If married, this process will be repeated for the spouse . NOTE: – Section: Resource Details Burial Arrangement Details This section asks the applicant and the applicant’s spouse (if married) to provide information regarding any pre - paid arrangements for funeral or burial expenses . Instructions:  Do not have burial arrangements – If the applicant and the applicant’s spouse do not have burial arrangements, he or she must check the first box. Select between Yes or No from the drop box on the left  – Irrevocable prepaid contracts and then type the current value in the field on the right. – Select between Yes or No from the drop box on the left and  Revocable prepaid contracts then type the current value in the field on the right.  – Select between Yes or No from the drop box on the left and then type Burial Space items the current value in the field on the right. NOTE: Burial space items include plots, caskets, headstones, vaults and opening/closing costs.  Other funds set aside – Select between Yes or No from the drop box on the left and then type the current value in the field on the right. NOTE: Other money for burial must be in a separate account specifically designated for burial.  Click Save and Next If married, this process will be repeated for the spouse . NOTE:  INSTRUCTIONS NJ SAVE 17 OCT 2018

18 Section: – Program Eligibility Lifeline This section is used to determine eligibility for the annual $225 utility benefit provided through the Lifeline Utility Assistance Program. If the applicant is not a utility customer but a tenant, they will complete the Rent and Residence Details and Landlord Details . If the applicant received a message that he or she is not eligible for Lifeline Utility Assistance Program, they will move to the following section. There is only one Lifeline benefit per household. Instructions: Select between Yes, None or Both.  – Are you, or your spouse an electric or gas customer NOTE: If yes or both is selected, a new set of fields will appear for the applicant to enter  information about their utility accounts. If no is selected, a new question will appear regarding being a tenan t.  Are you a tenant and your utilities are included in your rent – Select between Yes or No message box is selected, a new set of fields will appear. If no is selected, a If yes  NOTE: Lifeline Utility will appear informing the applicant that he or she is not eligible for Assistance Program. They must click OK and then Click Save and Next Section: Lifeline Utility Details – utility information . This section asks the applicant to provide Instructions:  Select your Electric Company – The applicant must select his or her electric company from the drop down list. account number The applicant must type the .  Account Number –  First Name on bill – Type first name. Last Name on bill –  Type last name.  Relationship to Applicant – The applicant must select his or her relationship to the person listed on the utility bill from the drop down list. repeated for If the applicant listed both electric and gas, a section will need to be NOTE: information. account the gas company and INSTRUCTIONS NJ SAVE 18 OCT 2018

19 Section: Lifeline – Rent and Residence Details to provide rental amount information. This section asks the applicant Instructions:  List the monthly amount of rent – The applicant must type his or her monthly rent amount.  Principal place of residence description – The applicant must select the option that most accurately describes his or her place of residence from the drop down list.  Other – If other was selected, t he applicant must type the description . – Section: Lifeline Landlord Details the applicant and the applicant’s spouse (if married) This section asks information to provide regarding his or her landlord. Instructions:  Landlord’s Name – The applicant must type the landlord’s name. / City / State / Zip Code must the landlord’s type  Landlord’s Address The applicant – street address (Number, street, apartment or floor number). The applicant must type the . city. Select the state abbreviation from the drop down box and type the zip code  Click Save and Next INSTRUCTIONS NJ SAVE 19 OCT 2018

20 Section: USF / LIHEAP section is used screen the applicant and spouse for USF/LIHEAP eligibility . USF is an This - income electric and natural gas customers . LIHEAP helps energy assistance program for low . Both programs are meet home heating costs low income families and individuals by New Jersey Department of Community Affairs. administered Instructions: you Are or your spouse an electric or gas customer  – The information is pre - fill ed from the Lifeline section.  Indicate the number of persons residing in the household – The applicant must type the amount of persons.  Total gross income for all household members – The applicant must type the total gross income for all members who are aged 18 and older. Do you pay for your own heat . Select between Yes or No –  –  Select primary source of heat The applicant must select the option that most accurately describes the primary source of heat from the drop down list. Enter heating fuel supplier name - The applicant must type the name of company.  Save and Next Click  Section: Attachment Details allow s the applicant to attach documents to the online application. This section Instructions:  NOTE: To access the descriptions for required documents, the applicant can click on the shaded section headers . The applicant will select the type of document. The applicant will then click on browse to attach the file saved to his or her computer files. Once the and selected, click the attach button. document file is saved to their computer If the appli cant does not want to attach the documents they may mail or fax them NOTE:  to DoAS at the address and number on this page. Please include the confirmation number on any documentation submitted by mail or fax. INSTRUCTIONS NJ SAVE 20 OCT 2018

21 Section: Review This section allow s the to review the information entered on the online application. applicant Instructions:  NOTE: To access the information that the applicant entered on the online application, the applicant can click on the shaded section headers . If the applicant needs to ed it button for the section that needs to be dit informati on, he or she can click on the E updated. Section: Sign - Off Instructions: NOTE:  The applicant must read the sign - off notice carefully.  NOTE: If the applicant is not registered to vote where they live, he or she can apply to register. The applicant can view the Voter Opportunity Information Form and the Voter or Spanish English . If Registration Application in either English or Spanish by clicking on the applicant would like a Voter Registration Application mailed to them, he or she must select between Yes from the drop down list. Section: - Off / Assistance with Application Sign Instructions:  Did someone assist you in completing this applicat ion – Select between Yes or No from the drop down list.  Select the best option to describe the contact person – The applicant must select the option that most accurately describes the person assisting from the drop down list. First Name  – Type the assisting person’s first name.  Last Name – Type the assisting person’s last name.  Mailing Address – Type the assisting person’s address (Number and Street) in line 1 and ( apartment or floor number ) in Apt#. The applicant must type the city. Select the state abbreviation from the drop down box and type the zip code . –  Phone Number Type the contact person’s phone number. The Preparer (assister) must check the box to electronically sign the application. NOTE: INSTRUCTIONS NJ SAVE 21 OCT 2018

22 Section: Off / Zero Income and Resources reported - Sign Instructions: Zero Income and Resources reported – If the applicant reported on the application that he  any does not receive any income or does not have resources, he or she must type a or she response in the box indicating how he or she meet their daily needs. The application must check the box that verifies that the information that he or NOTE: The applicant must check the next box she entered on the application is true and correct. to electronically sign the application.  Click Subm it Application Section: TARC Sign - Off Instructions: If the applicant indicated NOTE: Off section that he or she received assistance - in the Sign  with the application with a representative from the Trans Atlantic Renal Council (TARC), - that individual must complete this form. Otherwise, the application will continue. Section: Confirmation Instructions:  NOTE: Once the applicant has submitted the application, he or she will receive the confirmation. This will include the confirmation number of the application and the date that it was completed. The applicant must read this information carefully. The submission of this application is not the immediate approval of benefits. The applicant should not apply again while this application is still in pro cess. NOTE:  If the applicant would like to apply for the Hearing Aid Assistance to the Aged and Disabled (HAAAD) for reimbursement for a hearing aid , he or she must check the box. The applicant may be reimbursed $100 for the purchase of a hearing aid.  NOTE: If the applicant would like to apply for the Supplemental Nutrition Assistance Program (SNAP), he or she must check the box.  NOTE: The applicant can view documents needed to be attached to the online application . The applicant can print out th is page or the entire application to keep for his or her records by clicking the print button on the bottom of the page. . Continue to S Click urvey  INSTRUCTIONS NJ SAVE 22 OCT 2018

23 Section: Feedback This section allows the applicant to provide feedback on his or her experience with the . application Instructions: The applicant must indicate how he or she heard about our division or our  NOTE: programs. The applicant can also enter any suggestions or comments regarding the c . A box will appea r informing the applicant Done lick application. The applicant can then that the application is completed. Click OK to logout.  INSTRUCTIONS NJ SAVE 23 OCT 2018

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