WPA-9, JACC 404, JACC CO-Pay WORKSHEET
New Jersey Department of Human Services2020 JACC CO-PAY WORKSHEET1.Participant: FORMTEXT ?????2.JACC ID No.: FORMTEXT ?????3.Care Management Site: FORMTEXT ?????4.Care Manager No.: FORMTEXT ?????Income(All amounts entered as gross unless otherwise indicated.)MonthlyAnnual5Social Security Retirement (Net) FORMTEXT ????? FORMTEXT ?????6Social Security Disability (Net) FORMTEXT ????? FORMTEXT ?????7Pensions FORMTEXT ????? FORMTEXT ?????8Interest Bearing Accounts FORMTEXT ????? FORMTEXT ?????9VA Pension (do not include Aid & Assistance) FORMTEXT ????? FORMTEXT ?????10Alimony FORMTEXT ????? FORMTEXT ?????11Earnings, Salary, Tips FORMTEXT ????? FORMTEXT ?????12Worker’s Compensation FORMTEXT ????? FORMTEXT ?????13Net Rental Income FORMTEXT ????? FORMTEXT ?????14Unemployment Benefits FORMTEXT ????? FORMTEXT ?????15Income of Spouse FORMTEXT ????? FORMTEXT ?????16Disability Income FORMTEXT ????? FORMTEXT ?????17Other Income FORMTEXT ????? FORMTEXT ?????18Total FORMTEXT ????? FORMTEXT ?????Deductions19Supplemental Medical Insurance Premium FORMTEXT ????? FORMTEXT ?????20Prescribed Medical Expenses not reimbursed by insurance FORMTEXT ????? FORMTEXT ?????21Subtotal deductions or standard deduction of $233 individual, $451?couple FORMTEXT ????? FORMTEXT ?????22Income minus deductions FORMTEXT ????? FORMTEXT ?????(line 18) FORMTEXT ?????minus (line 21) FORMTEXT ?????23Amount of Co-Pay Due FORMTEXT ????? FORMTEXT ?????SIGNATURES:24. Participant: FORMTEXT ?????Date: FORMTEXT ?????25. Care Manager: FORMTEXT ?????Date: FORMTEXT ?????Monthly IncomeCo-PayAmountIndividualCouple$0 – 1,414$0 – 1,911$0.00$1,415 – 1,861$1,912 – 2,514$15.00$1,862 – 2,393$2,515 – 3,233$30.00$2,394 – 2,924$3,234 – 3,951$60.00$2,925 – 3,456$3,952 – 4,669$90.00$3,457 – 3,881$4,670 – 5,244$120.00 ................
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