WPA-9, JACC 404, JACC CO-Pay WORKSHEET - New Jersey
New Jersey Department of Human Services
2019 JACC CO-PAY WORKSHEET
|1. Participant: | |2. JACC ID No.: | |
|3. Care Management Site: | |4. Care Manager No.: | |
|5 |Income |Monthly |Annual |
| |(All amounts entered as gross unless otherwise indicated.) | | |
|6 |Social Security Retirement (Net) | | |
|7 |Social Security Disability (Net) | | |
|8 |Pensions | | |
|9 |Interest Bearing Accounts | | |
|10 |Veteran’s Administration Benefits | | |
|11 |Alimony | | |
|12 |Earnings, Salary, Tips | | |
|13 |Worker’s Compensation | | |
|14 |Net Rental Income | | |
|15 |Unemployment Benefits | | |
|16 |Income of Spouse | | |
|17 |Disability Income | | |
|18 |Other Income | | |
|19 |Total | | |
|20 |Deductions | | |
|21 |Supplemental Medical Insurance Premium | | |
|22 |Prescribed Medical Expenses not reimbursed by insurance | | |
|23 |PEP Insurance: Liability and Worker’s Comp | | |
|24 |Subtotal deductions or standard deduction of $228 individual, $442 couple | | |
|25 |Income minus deductions | | |
| |(line 19) | |minus (line 24) | | | | |
| | | | |
|26 |Amount of Co-Pay Due | | |
|SIGNATURES: |
|27. Participant: | |Date: | |
|28. Care Manager: | |Date: | |
|SIX MONTH REVIEW: |
|29. Participant: | |Date: | |
|30. Care Manager: | |Date: | |
|Monthly Income |Co-Pay |
| |Amount |
|Individual |Couple | |
|$0 – 1,383 |$0 – 1,873 |$0.00 |
|$1,384 – 1,820 |$1,874 – 2,465 |$15.00 |
|$1,821 – 2,341 |$2,466 – 3,170 |$30.00 |
|$2,342 – 2,861 |$3,171 – 3,874 |$60.00 |
|$2,862 – 3,382 |$3,875 – 4,579 |$90.00 |
|$3,383 – 3,799 |$4,580 – 5,143 |$120.00 |
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