New Jersey Department of Health

AIDS Drug Distribution Program (ADDP) and

Health Insurance Continuation Program (HICP)

PO Box 722

Trenton, NJ 08625-0722

CERTIFICATION OF SEPARATION

Date of Initial Separation:
Name of Applicant:
Legal Residence of Applicant:
Street Address:
City, State, Zip Code:
Name of Spouse:
Legal Residence of Spouse:
Street Address:
City, State, Zip Code:

I, ______________________________________, certify and attest to the truthfulness

(Print Name of Applicant)

of the following:

1.	That my spouse and I are separated and no longer reside together.

2.	That I have no access to the funds of my spouse.

3.	That I receive no support or monies from my spouse.

4.	That my spouse and I do not mingle or join our funds in any way including the filing of joint federal or state income tax returns.

I certify that the foregoing statements made by me are true.

Signature of Applicant	Date

DHAS-40

APR 15

dhas- Certification of Separation

ewhite

2015-04-13

njdoh