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Effective Date: April 1, 2009

Approval Date: ____________ 2

MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN'S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: ___________________New Jersey________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

__________________________/S/______________________________________________ Jennifer Velez [James M. Davy]

Date (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children's Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Jennifer Velez [James M. Davy]

Position/Title: Commissioner, Department of Human Services Name: John R. Guhl [Ann Clemency Kohler] Position/Title: Director, Division of Medical Assistance and Health Services Name: Carol Grant [Michelle Walsky] Position/Title: Chief of Operations, Division of Medical Assistance and Health Services Name: Michael P. Keevey [John R. Guhl]

Position/Title: Chief Financial Officer, Division of Medical Assistance and Health Services

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