Application Forms

New Jersey State Organization of Cystic Fibrosis

Program Requirements:

1. DIAGNOSIS OF CYSTIC FIBROSIS VERIFIED BY CF DOCTOR.
2. MUST BE A NEW JERSEY RESIDENT.
3. MUST BE 18 YEARS OR OLDER.
4. INDIVIDUAL ANNUAL INCOME LESS THAN $44,319 / YEAR.

Complete the application and return it with all required documents to:

The documents needed to process your application are:

• Completed "Application".
  • Copy of your NJ Driver’s License AND Birth Certificate.
• Completed “Insurance Affidavit”.
  • Copies of all current Health Insurance Cards.
• Signed and notarized “Income and Acceptance Affidavit”.
  • Copy of your 2009 Federal Tax Return with all W2’s and/or your SSI Benefits Statement.
• Signed and completed “Pathmark Selection Form" OR "Wegman's Selection Form”.

Failure to submit ALL of the above items will delay your acceptance into the Program.

How to get the forms:

• Required Application Forms
  and list of Pathmark
  & Wegman's Stores.
  PDF format.