Odjfs 07120 form 2026

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Click ‘Get Form’ to open the odjfs 07120 form in the editor.
Begin with Section A. Fill in your name, Social Security Number, facility name and address, phone number, city, state, zip code, and county. Ensure all information is printed legibly.
If applicable, provide the name and address of your representative payee or legal guardian along with their phone number.
Proceed to Section B. This section must be completed by the County Department of Job and Family Services (CDJFS). Indicate whether the individual is currently on Medicaid by selecting 'Yes' or 'No'.
Complete any additional fields such as spenddown amount and MITS claim number if necessary.
In Section C, sign and date the form. If you are a representative payee or legal guardian, ensure you sign on behalf of the individual needing RSS.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (102 Votes)
2012	4 Satisfied (48 Votes)

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