Application for renewal of health coverage nj familycare pdf

What you may need to renew coverage

Renewing is easy to do

We’ve tried to make the renewal process as easy as possible. This way, you’ll be sure to keep your health benefits. You can choose from a few ways to renew:

By mail

Send your completed renewal form back before your stated due date. The address will be on your renewal notice.

In person

Just visit your local outreach and enrollment site for a list of local agencies that can help you renew in person. 

Do you live in Essex County? If yes, you can also visit Healthcare Central. This is an Aetna Better Health of New Jersey location. We’ll walk you through the steps, answer questions and help you understand the renewal forms.

Just call before you visit in person to be sure your location is open.

Why renew on time every year?

Renewing on time every year allows you to:

• Keep health care coverage for you and your family
• Enjoy peace of mind, knowing you and your family are covered
• Stay as healthy as you can, so you can be there for your family

Questions about renewing

Not sure when your renewal date is? Or didn’t get your renewal form? No problem. Just call NJ FamilyCare at 1-800-701-0710 (TTY: 1-800-701-0720).

What to know if you’re an immigrant

Join us

If you’re eligible for NJ FamilyCare, you can choose us as your health plan. Need to learn more? Just call our Healthcare Central Store at 959-299-3102 (TTY: 711). We’re here for you Monday through Friday, 10 AM to 6 PM ET.

NJFamilyCare is a government-sponsored health insurance program that provides affordable health insurance to uninsured and underinsured New Jersey residents. The NJFamilyCare application process can be completed online, and it only takes a few minutes to apply. In this blog post, we will walk you through the steps of applying for NJFamilyCare online. Keep in mind that you must reside in New Jersey and meet the eligibility requirements to qualify for coverage.

Here is the data regarding the PDF you were in search of to fill in. It will tell you how much time it may need to finish njfamilycare application, exactly what parts you will need to fill in and some other specific details.

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Form Preview Example

Application for Health Coverage & Help Paying Costs

Use this application to see what coverage choices you qualify for

•Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP), known as NJ FamilyCare

•

you stay well

•A new tax credit that can help pay your premiums for health coverage

•In person: There may be counselors in your area who can help. Visit our website or call 1-800-701-0710for more information.

•En Español: Llame a nuestro centro de ayuda gratis al

1-800-701-0710.

STEP 1 Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name, Middle name, Last name, & Suffix

2. Home address (Leave blank if you don’t have one.)

3. Apartment or suite number

4. City

5. State

6. ZIP code

7. County

8. Current mailing address (if different from home address)

9. Apartment or suite number

10. City

11. State

12. ZIP code

13. County

16. Do you want to get information about this application by email? Yes No

Email address:

17. What is your preferred spoken or written language (if not English)?

STEP 2 Tell us about your family.

Family Planning (Plan First Program)

If any person on this application is not eligible for NJ FamilyCare, would you like them to be evaluated for family planning services (Plan First Program)?

Plan First is a program for women and men that provides only family planning and related services (such as birth control and reproductive health care). Family planning services do not provide minimum essential health care coverage (such as routine care).

Who do you need to include on this application?

DO Include:

•Yourself

•Your spouse

•Your children under 21 who live with you

•Your unmarried partner who needs health coverage

•Anyone you include on your tax return, even if they don’t live with you

•Anyone else under 21 who you take care of and lives with you

You DON’T have to include:

•Your unmarried partner who doesn’t need health coverage

•Your unmarried partner’s children

•

(if you’re over 21)

•

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family, you’ll need to make a copy of the pages and attach them.

You don’t need to provide immigration status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 1 of 7

NJFC-APP-E-0919

STEP 2: PERSON 1 (Start with yourself)

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you

with you.

1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

SELF

3.Date of birth (mm/dd/yyyy)

5.Sex Male Female

Official Name on Immigration Document/Card (AKA) ____________________________________________________________

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

7a. Check this box if you plan to file a federal income tax return NEXT YEAR.

(You can still apply for health insurance even if you don’t file a federal income tax return.)

Will you file jointly with your spouse?

Yes No

If yes, name of spouse:

Will you claim any dependents on your tax return? If yes, list name(s) of dependents:

Yes No

7b. Check this box if you will be claimed as a dependent on someone’s federal tax return.

If yes, please list the name of the tax filer:

How are you related to the tax filer?

8. Are you pregnant? Yes

No a.If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

9.Do you need health coverage?

(Even if you have insurance, there might be a program with better coverage or lower costs.)

YES. If yes, answer all the questions below.

NO. If no, SKIP to the income questions on page 3. Leave the rest of this page blank.

10. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc) or live in a medical facility or nursing home?

Yes

No

11. Do you want help paying for medical bills from the last 3 months?

Yes

No

12. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?

Yes

No

13. Are you a full-time student?

Yes

No

14. Were you in foster care at age 18 or older?

Yes

No

15.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

16.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro Samoan

Other

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 2 of 7

NJFC-APP-E-0919

26.If self-employed, answer the following questions:

27.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

28. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).

29.YEARLY INCOME: Complete only if your income changes from month to month.

If you don’t expect changes to your monthly income, skip to the next person.

THANKS! This is all we need to know about you.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 3 of 7

NJFC-APP-E-0919

Guamanian or Chamorro Samoan

Other

Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you

with you.

1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

3. Date of birth (mm/dd/yyyy)

Official Name on Immigration Document/Card (AKA) ____________________________________________________________

8a. Check this box if PERSON 2 plans to file a federal income tax return NEXT YEAR.

(You can still apply for health insurance even if you don’t file a federal income tax return.)

Will PERSON 2 file jointly with their spouse?

If yes, name of spouse:

Yes No

8b.

Will PERSON 2 claim any dependents on their tax return? Yes No

If yes, list name(s) of dependents:

Check this box if PERSON 2 plans to be claimed as a dependent on someone’s federal tax return. If yes, please list the name of the tax filer:

How is PERSON 2 related to the tax filer?

9. Is PERSON 2 pregnant?

Yes

No a. If yes, how many babies are expected during this pregnancy? _________ Due Date _______________

10.Does PERSON 2 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)

11.Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No

Please answer the following questions if PERSON 2 is 22 or younger:

16.Is PERSON 2 a full-time student? Yes No

17.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)

18.Race (OPTIONAL—check all that apply.)

White

Black or African American

Native American Indian or Alaska Native Asian Indian

Chinese

Vietnamese

Other Asian

Native Hawaiian

Now, tell us about any income from PERSON 2

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 4 of 7

NJFC-APP-E-0919

STEP 2: PERSON 2

Current Job & Income Information

CURRENT JOB 1:

28.If self-employed, answer the following questions:

29.OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).

30. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.

If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 29b).

31.YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.

If you don’t expect changes to PERSON 2’s monthly income, add another person or skip to the next section.

THANKS! This is all we need to know about PERSON 2.

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 5 of 7

NJFC-APP-E-0919

STEP 3 Native American Indian or Alaska Native (AI/AN) family member(s)

1.Are you or is anyone in your family Native American Indian or Alaska Native?

If No, skip to Step 4. Yes. If yes, go to Appendix B.

STEP 4 Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1.Is anyone enrolled in health coverage now from the following?

2.Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job, such as a parent or spouse.

YES. If yes, you’ll need to have your employer complete Appendix A and return to address provided.

NO. If no, continue to Step 5.

STEP 5 Select your Health Plan

If you need assistance selecting your Health Plan, contact a Health Benefits Coordinator at 1-800-701-0710, TTY 1-800-701-0720.

Choose one:

Aetna Better Health® of New Jersey (Available in ALL counties)

Amerigroup New Jersey, Inc. (Available in ALL counties)

Horizon NJ Health (Available in ALL counties)

UnitedHealthcare Community Plan (Available in ALL counties)

WellCare Health Plans of New Jersey (Available in ALL counties, except Hunterdon county)

I understand that if I’m found eligible and because I have joined a Health Plan, I must follow the rules for obtaining health care from the Health Plan. I understand that I must let my Health Plan and NJ FamilyCare know if there is any change in the number of people in my family and that any newborn children will be enrolled in my Health Plan. I understand that, unless I, or a family member, have a true medical emergency, I must call my personal doctor for medical advice, medical care or for a referral to a specialist. I understand that if I, or a family member, have a true medical emergency, I must call my personal doctor or the Health Plan as soon as possible after I, or the family member, go to the hospital. I understand that I must keep any medical appointment I have scheduled with a doctor and, if I cannot, I must call the doctor’s office to cancel the appointment. I understand that if I go to a doctor other than my personal doctor I have selected, without a referral from my doctor or

approval from the Health Plan, I may have to pay for that doctor’s services because NJ FamilyCare will not pay for the unapproved service or visit. I understand that I may change to another Health Plan and that I can call the Health Benefits Coordinator to help me do that. I give permission

for the release of my medical history and health care records and those of my family members who will be enrolled to any person(s) in the Health Plan and its providers who shall provide or coordinate health care to me and my family as long as I am a member of the Health Plan.

FOR OFFICE USE ONLY

Page 6 of 7

NJFC-APP-E-0919

STEP 6 Read & sign this application.

•I understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it.

•

•I understand that the outcome of this application may be shared with any Provider providing services or who provided

•I understand that I must tell NJ FamilyCare immediately about any changes in my information, such as a change in income, address, family size, if someone in my household is expecting a baby, or if anyone in my household who applied for

member(s) of my household. I know that I must call 1-800-701-0710 (TTY 1-800-701-0720)to report any changes.

•I authorize the NJ Division of Taxation to release my tax return information to NJ FamilyCare.

•I also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, NJ Division of Taxation, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Renewal of coverage in future years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and I can opt out at any time.

If anyone on this application is eligible for NJ FamilyCare

•I am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the NJ FamilyCare agency rights to pursue and get medical support

•If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell NJ FamilyCare and I may not have to cooperate.

My right to appeal

If I think NJ FamilyCare has made a mistake, I can appeal its decision. To appeal means to tell someone at NJ FamilyCare that I

NJ FamilyCare at 1-800-701-0710. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me.

Estate Recovery

I understand that Medicaid payments for services received on or after age 55 may be reimbursable to the State of New Jersey

be limited to, capitation payments made to a managed care organization (MCO) or transportation broker for health coverage,

transportation broker. For more information about Estate Recovery, visit http://www.state.nj.us/humanservices/dmahs/ clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_You_Should_Know.pdf

Sign this application.

may sign here, as long as you have provided the information required in Appendix C.

Signature

Date (mm/dd/yyyy)

NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with 42 U.S.C. 1320b-7.

The SSNs provided (including for a husband or wife, family members, or dependents) will be used to associate records pertaining to applicants and other

to the extent it is useful in verifying eligibility or the amount of medical assistance payments under 42 CFR 435.940 through 435.960, and preventing duplicate

audits. These procedures are designed to determine eligibility and to identify persons who fraudulently or wrongfully participate in Medicaid and DMAHS

STEP 7 Mail Completed Application.

Mail your signed application to: NJ FamilyCare

PO BOX 8367

TRENTON, NJ 08650-9802

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

Page 7 of 7

NJFC-APP-E-0919

APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this

Tell us about the job

You need to include this page when you send in your application.

EMPLOYEE Information

EMPLOYER Information

No (Stop here and go to Step 5 in the application)

Tell us about the health plan

d*? Yes No

15.For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a.How much would the employee have to pay in premiums for this plan? $

16.What change will the employer make for the new plan year (if known)?

Employer

the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $

Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

APPENDIX B

Native American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs.

Tell us about your Native American Indian or Alaska Native family member(s).

Native American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSON 1

AI/AN PERSON 2

•Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

•Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations)

•Money from selling things that have cultural significance

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710 . If you need help in a language other than English, call 1-800-701-0710and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-701-0720.

NJFC-APP-E-0919

APPENDIX C

Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact NJ FamilyCare. If you’re a legally appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

By signing, you allow this person to sign your application, getinformation about this application, and act for you on all future matters with this agency.

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1.Application start date (mm/dd/yyyy)

2.First name, Middle name, Last name, &

NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710 . If you need help in a language other than English, call 1-800-701-0710and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-701-0720.

NJFC-APP-E-0919

STATE OF NEW JERSEY

Department of Human Services

Division of Medical Assistance and Health Services

Non-DiscriminationStatement

DiscriminationisAgainsttheLaw

NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. NJ FamilyCare does not exclude people or treat them differently because of race, color, national origin, sex, age or disability.

NJFamilyCare:

•Provides free aids and services to people with disabilities to communicate effectively with us, such as:

–Qualified sign language interpreters

–Written information in other formats (large print, audio, accessible electronic formats, other formats)

•Provides free language services to people whose primary language is not English, such as:

–Qualified interpreters

–Information written in other languages

If you need these services, please contact 1-800-701-0710 (TTY: 1-800-701-0720).

If you believe that NJ FamilyCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, sex, age or disability, you can file a grievance with the NJ FamilyCare Civil Rights Coordinator via the following: NJ Civil Rights Coordinator, NJ Department of Human Services, Office of Legal and RegulatoryAffairs, P.O. Box 700, Trenton, NJ 08625-0700,1-888-347-5345 or email: . If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also electronically file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services SW, Room 509F, HHH Building

200 IndependenceAvenue Washington, D.C. 20201

1-800-368-1019,1-800-537-7697 (TDD)

U.S. Department of Health and Human Services complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

NJFC-NDS-0719

New Jersey Non-Discrimination Statement

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Voter Registration Application

Please print clearly in ink. All information is required unless marked optional.

o“I swear or affirm that I DO NOT have a NJ Driver’s License, MVC Non-driver ID or a Social Security Number.”

9Former Name if Making Name Change

a.Day Phone Number (Optional)

b.E-MailAddress (Optional)

11Gender o Female o Male

Declaration - I swear or affirm that:

• I am a U.S. Citizen

• I live at the above address

• I am at least 17 years old, and under- stand that I may not vote until reaching the age of 18.

• I will have resided in the State and county

at least 30 days before the next election

• I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws

• I understand that any false or

fraudulent registration may subject me to a fine of up to $15,000, imprisonment up to 5 years, or

both pursuant to R.S. 19:34-1

Signature: Sign or mark and date on lines below

If applicant is unable to complete this form, print the name and address of individual who completed this form.

Name

Date

Address

Important Instructions for sections 5, 6 and 10

5)Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place.

Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties.

6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of your time.

10)You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 10 is OPTIONAL and will not affect the acceptance of your voter registration application.

Need More Information? Check boxes below if you would like to receive more information about:

For further information visit Elections.NJ.gov or call toll-free1-877-NJVOTER(1-877-658-6837)

NJ Division of Elections - 02/16/16

New Jersey

Voter Registration Information

You can register to vote if:

n You are a United States citizen. n You are at least 17 years of age.*

n You will be a resident of the State and county 30 days before the election.

n You are NOT currently serving a sentence, probation or parole because of a felony conviction.

*You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18.

Registration Deadline: 21 days before an election

Your County Commissioner of Registration will notify you if your application is accepted.

If it is not accepted, you will be notified on how to complete and/or correct the application.

Questions? visit Elections.NJ.gov or call toll-free1-877-NJVOTER(1-877-658-6837)

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Important: Print out at 100% - DO NOT REDUCE. Fold as illustrated to ensure proper mailing.

New Jersey

Voter Registration

You can register to vote if:

nYou are a United States citizen

nYou will be 18 years of age by the next election

nYou will be a resident of the county 30 days before the election

nYou are NOT currently serving a sentence, probation orparole because of a felony conviction

Registration Deadline: 21 days before an election

Your County Commissioner of Registration will notify you if your application is accepted.

If it is not accepted, you will be notified on how to complete and/or correct the application.

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