New Jersey Department of Human Services

Adult Day Services Program for Persons with Alzheimer's Disease or Related Disorders

PO Box 807

Trenton, NJ 08625-0807

FINANCIAL PROFILE

Name of Client

Name of Agency

Street Address

Social Security Number

City, State, Zip Code

County

Name of Primary Caregiver

Relationship

Street Address

Telephone Number

( )
City, State, Zip Code

Yearly Income of Client or Couple (if Married)	Assets of Client or Couple (if Married)
Type	Value	Specify Type of

Verification on File	Type	Value	Specify Type of

Verification on File
Wages	Bank Account Balances
Social Security (before Medicare is deducted)	Value of Stocks
SSI	Value of Bonds
VA	Value of CD’s
Pensions	Value of Annuities
Interest, Dividends, Trusts	Cash Surrender Value of Life Insurance
Other	Other
Total Income
Adjusted Income*	Total Value of Assets
*Submit Form WFS-11 Extraordinary Financial Obligations if reporting adjusted income.

Marital Status

Single	Divorced

Married	Widowed	Living Arrangements

Alone	With Family

With Spouse Only	Other
CERTIFICATION: I certify that the above is true and accurate to the best of my knowledge.
Signature of Primary Caregiver	Date

Name of Agency Representative

Title

Signature	Date

CSS-7

JUL 12	Distribution: Original-NJDHS Copy-Agency Copy-Family

CSS-7 , Financial Profile

aging services, alzheimer's adult day services, DAS

2004-05-10

ewhite

human services