STEVE SISOLAK
Governor
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
RICHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
Date:
Case Name:
Case ID:
AUTHORIZATION: I authorize you to release to
the Division of Welfare and Supportive Services the
requested information.
Client Signature Date
SNAP AFFIDAVIT OF SEPARATE HOUSEHOLD
Please provide the requested information below and return to the above address. Your cooperation ensures program
integrity and maintains accountability in administering public funds in Nevada. The provided information is used only in
conjunction with the official duties of this agency and is confidential. An immediate response would be appreciated.
If our identifying information (name and address) disagrees with your records, please indicate the change.
RE:
Name Street/Residence Address
To determine the above-mentioned applicant/recipient's eligibility as a separate food unit, the following information is
requested. Please complete this form and return no later than undefined.
1. What is your relationship to the above-mentioned applicant/recipient?
2. Do you purchase and prepare your food separately from the above-mentioned applicant/recipient? YES NO
3. What amount do you (check one) charge or pay the above-mentioned SNAP applicant/recipient separately for rent? Enter
amount
$
. (If none, write none)
4. What amount do you (check one) charge or pay the above-mentioned SNAP applicant/recipient separately for utilities? Enter
amount $_________. (If none, write none)
What does the amount charged for utilities include (please check all that applies)?
Heat Air Conditioning/
Cooling
Telephone Water Sewer Garbage Lights Gas for
cooking
5. If you do not charge or pay a separate amount for rent and utilities (questions #3 and #4), what total amount is the above-mentioned
SNAP applicant/recipient charged or paid for rent and utilities combined? Enter amount
$
. (If none, write none)
6. Please provide the portion of the most current electric or gas bill showing the service address for which utilities expenses are being
requested by the SNAP applicant/recipient mentioned above.
Signature of person completing form Relationship
Person completing form
Address Date Phone
2008 - EF (211.0.0)
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