New Jersey Department of Human Services

APPLICATION FOR LETTER OF AGREEMENT FOR HEALTH SERVICES

ADULT DAY SERVICES PROGRAM FOR

PERSONS WITH ALZHEIMER'S DISEASE OR RELATED DISORDERS

Name of Applicant

Employer ID No.

Street Address	City	State	Zip Code

Type of Agency	County

Private Non‑Profit	Other (Specify):
Government
Type of Request
New	Modification to LOA No.:
Grantee Fiscal Year Ends (Month/Day/Year)	Budget/Project Period to Begin (Month/Day/Year)
/	/
/	/
Name and Title of Principal Contact

Telephone Number

Name and Title of Fiscal Contact

Telephone Number

Site Location(s)
Does any member of the Board of Directors/Trustees serve on any board, council, commission, committee or Task Force which has regulatory or advisory influence on the funding program?
Yes	No	If Yes, Member:
Board, Council:
If political subdivision, is applicant covered by NJ Civil Service Merit System?

Yes	No
Does applicant have an Affirmative Action Plan?

Yes	No
If awarded, will funds be used to replace other funds which would be available in absence of award?

Yes	No
CERTIFICATION

The applicant certifies that to the best of his/her knowledge and belief all data supplied in this application and attachments are true and correct, the document has been duly authorized by the governing body of the applicant, and further understands and agrees that any funds received as a result of this application shall be subject to the conditions and other policies, regulations and rules issued by the New Jersey Department of Human Services for the administration of letters of agreement for health services which include provisions described in the application instructions.

Name of Certifying Representative

Title

Signature	Date

CSS- (formerly WFS-9)

MAR 06

CSS-12

JUL 12

CSS-12, Application for letter of agreement for health services

LOA, CSS-12, letter of agreement, health services, alzheimer's disease, adult day services

Windows User

2016-03-24

human services