Fillable Application for Assistance (State of Nevada, Department of Information Technology)

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Application for Assistance (State of Nevada, Department of Information Technology)

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2905 – EG (8-17)
Division of Welfare and Supportive Services
Application for Assistance
“Working for the Welfare of ALL Nevadans”
Programs You May Apply For:
Food Assistance from the Supplemental Nutrition Assistance Program (SNAP) helps people buy food.
Temporary Assistance for Needy Families (TANF) helps families with children meet their basic needs with cash assistance.
Time Frames
SNAP benefits are processed within 30 days from the date of the application. If your household has little or no income, you
could receive SNAP benefits within 7 days from the date of your application. SNAP benefits are paid from the date of the
application.
TANF benefits are paid from the date of approval or 30 days from the date of the application, whichever is sooner. TANF
applications are processed within 45 days from the application date unless there are unusual circumstances.
Denial of benefits for one program does not automatically affect the decision on another program you may be applying for.
SNAP Expedite Rules
The following households are entitled to expedited service and should receive SNAP benefits within 7 days:
Households with less than $150 in monthly gross income and no more than $100 in liquid resources;
Migrant or seasonal farm worker households who are destitute, provided their liquid resources do not exceed $100;
Households with combined monthly gross income and liquid resources less than the household’s monthly rent or mortgage
and utilities.
Social Security Numbers
You will be asked to provide Social Security Numbers (SSN) for all persons (including yourself) who are applying for assistance,
pursuant to Title 42 USC 1320b-7 and is authorized under the Food and Nutrition Act of 2008 (formerly the Food Stamp Act), as
amended 7 U.S.C. 2011-2036. Providing or applying for a SSN is voluntary. For SNAP, any person who wants assistance but does
not want to give information about his or her SSN will not be eligible for benefits. Other family or household members may still get
benefits if they are otherwise eligible. For TANF, if a required household member fails or refuses to provide an SSN without good
cause, the entire household will be ineligible for TANF benefits. This includes all individuals whose income and needs are used to
determine eligibility for the TANF program.
SSNs are used to verify your household’s income and resources and to conduct computer matching with other agencies such as the
Social Security Administration, Employment Security Division, Child Support Enforcement Programs and the Internal Revenue
Service. It is also used to gather workforce information, investigations, recover overpaid benefits and to ensure duplicate benefits
are not received.
Citizenship/Immigration Status
You will be required to provide information about the citizenship and/or immigration status for all persons (including yourself) who
are applying for assistance. For SNAP, if any of these persons do not want to give us information about his/her citizenship and/or
immigration status, he/she will not be eligible for benefits. Other family or household members may still receive benefits if they are
otherwise eligible. For TANF, if a required household member fails or refuses to provide verification of their status, the entire
household will be ineligible for TANF benefits. Qualified Non-Citizen status is verified with the United States Citizenship and
Immigration Service (USCIS) for eligibility purposes. Information on non-applicants or non-qualified non-citizens will not be
shared with USCIS.
Where do I mail my completed application?
Send or submit your complete, signed application to the address below. Eligibility determinations will be based on rules and
requirements which pertain to the program you are applying for. We will notify you if you are eligible or not, or give you further
instructions for completing your application.
State of Nevada
Division of Welfare and Supportive Services
P.O. Box 15400
Las Vegas, NV 89114-5400
What if I need help with this application?
Phone: 1-800-992-0900 ext 47200 Southern Nevada (702) 486-1646 Northern Nevada (775)
684-7200
Email: welfare@dwss.nv.gov Online: https://dwss.nv.gov
In person: Visit our website or call 1-800-992-0900 ext 47200 to find a local DWSS District office
Language Interpreter: Call 1-800-992-0900 ext 47200 or TTY 1-800-326-6888
Applicant information, please keep this page for your records.
Non-Discrimination
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases
religion or political beliefs.
The U.S. Department of Agriculture (USDA) also prohibits discrimination based on race, color, national origin, sex, religious
creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or
funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,
audiotape, American Sign
Language, etc.), should contact
the Agency
(State or
local)
where they
applied for
benefits. Individuals
who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in languages other than English.
To file a complaint of discrimination, complete the USDA
Program Discrimination Complaint
Form, (AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at
any
USDA
office, or
write a letter
addressed to USDA
and provide in
the letter
all
of
the information requested in the form.
To request
a copy
of
the complaint
form, call
(866)
632-9992. Submit
your
completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary of Civil Rights
1400 Independence Avenue, S.W.
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email:
program.intake@usda.gov.
For
any
other
information
dealing with Supplemental
Nutrition Assistance Program
(SNAP)
issues, persons
should either
contact
the USDA
SNAP Hotline Number
at
(800)
221-5689, which is also in
Spanish
or
call
the State Information/Hotline Numbers
(click
the link for a listing of hotline numbers by State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
To file a complaint of disc
rimination regarding a program receiving Federal financial assistance through the U.S. Department of
Health and Human Services (HHS),
write: HHS Director,
Office for Civil Rights, Room 515-F
200 Independence Avenue, S.W.
Washington, D.C. 20201
or call: (202) 619-0403 (voice) or (800) 537-7697 (TTY).
This institution is an equal opportunity providers and employers.”
Applicant information, please keep this page for your records.
STEVE SISOLAK
Governor
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE
SERVICES
Notice of Required Verification
RJCHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
You may be required to provide proof of your household's circumstances to determine which benefits your household
will receive. This proof will be required for all people in your household. It will help the application process if you
provide the needed proof prior to or at your interview. The information below are examples of items you may be
required to provide to meet this requirement.
The documents you provide to us should cover a 30-60-day period prior to your date of application for benefits. Your
worker will provide you with more information regarding time periods.
If you are having trouble getting the required information, we can assist you. Please contact us at 702-486-1646 or
775-684-7200, if you need assistance. You can also refer to our website, https://dwss.nv.gov/, for general
information.
Identification/Citizenship
• United States Passport
• Government Issued Driver's
License/Identification Card
• U.S. Military ID (active,
dependent, retired)
• USCIS Verification of
Citizenship
• Certified United States Birth
Certificate
Unearned & Other Income
Copy of award letter or other
statement/verification for:
• Social Security Benefits (RSDI)
• Supplemental Security Income
(SSI)
• Worker's Compensation
• Unemployment Benefits
• Veteran's Benefits (retirement,
disability, educational)
• Retirement Pensions/Benefits
• Child Support Payments - Copy
of Court Order
• Alimony
• Cash Contributions/Loans
• TANF or other Government
Payment
• County or Indian General
Assistance
• Educational Income (Government
Grants, Student Loans, Scholarships,
etc.)
• Any other income received by any
household member
Earned Income
• Paycheck Stubs or Employer
• Statement
• If employment has ended in the
last 90 days, proof of termination
and final pay
• If unable to work, doctor's
statement
• Self-Employment Records/Tax
• Returns
Nevada Residency
• Current Lease or Rental
Agreement
• Nevada Driver's License
• Statement regarding homeless
situation
Out of State Benefits
• Proof of any benefits received
from another state
• Verification out-of-state benefits
• have been terminated
Resources
• Bank or Credit Union Statement
• Savings Bonds
• Vehicle Registration
• Life Insurance Policies
• Retirement Account Statements
• Trust Documents
• Proof of Stocks and Bonds
• Proof of Home or Property
Ownership
Expenses
Shelter Expenses
• Rent or Mortgage Receipt
• Current Utility Bill
• Signed & Dated Landlord Statement
• Proof of Home Taxes & Insurance
Educational Expenses
• Financial Aid Statement from School
• Receipts
Dependent Care
Receipt/Statement from sitter or daycare
center with the following information:
• Name of Sitter or Center
• Monthly Payment
• Names and ages of persons cared for
• Reason for Care
Court Ordered Child Support Paid
• Copy of Court Order
• Verification of Payments Made
2993-EG (3/19)
_______________
_______________
_______________
___________________________________
/
APPLICATION FOR ASSISTANCE
Please list everyone who lives in the home with you, whether you consider them household members or not. If someone is pregnant
please list the unborn child(ren) as household members as well. Please list the head of household first; you may choose who this
individual will be. The person chosen as the head of household will be the case name. Fill out as much of the application as you can; you
may ask for help if you need it. You may complete only your name, address and signature in order to start the application process
for Food Assistance. The remainder of the application may be submitted at or prior to your interview. You only need to answer
the questions designated for the programs for which you are applying. The remaining pages may be turned in, mailed or faxed to the
district office.
Last Name First Name
laitiIn e lddiM
.rS . rJ r eifidoM
Relation to
You
SELF
rGende
Date of
Birth
egA
l
*
a
*
ti
s
r
u
a
t
M
atS
Social
Security
Number
State or
Country
of Birth
nezi
ti
N
C
/
.
Y
S.U
yticinhtE/ecaR*
e
d
d
e
a
t
Gr
e
st
mplo
aL
C
r
a
d
e
e
Y
te
/htn
mpl
o
o
M
C
FOOD
FNAT
E ONN
Are there additional people in your home? YES NO If “YES”, list them on a separate sheet of paper.
Race - Please check one of the boxes that best describes your household - Hispanic/Latino or Non-Hispanic or Latino
*Ethnicity (Optional) - Please choose one of the following ethnicity codes for each household member: A-Asian; B-Black or African American; I-
American Indian or Alaska Native; J-American Indian or Alaska Native and White; L-Asian and White; M-Black or African American and White; N-
American Indian or Alaska Native and Black or African American; U-Native Hawaiian or Other Pacific Islander; W-White; Z-2 or more combinations
not listed above.
**Marital Status – Please choose one of the following marital status codes for each household member: D-Divorced; L-Legally Separated; M-Married;
N-Never Married; P-Separated; W-Widowed
Home Address (Give directions if you do not have an address.) City State Zip Code
Mailing Address (If
different from your home address.) City State Zip Code
Home Phone Cell/Message/Daytime Phone E-mail Address
If you are applying for Food Assistance, please answer questions 1 through 6 about your household. A Food
Assistance household includes all people who live and share food with you. Based on your answers below, you may
qualify for expedited service.
1. Do you usually buy, prepare and eat with other
s you live with? YES NO
If “NO”, list who buys their fo
od separately
2. List the total gross amount of money your hou
sehold received or expects to receive this month. $
3. How much do all persons have in cash, check
ing and savings accounts? $
4. How much is your current monthly cost for housing (rent/mortgage) and utilities? $
5. Are you or any person(s) in your household a migrant or seasonal farm worker?
YES NO
6. Have you or any person in your house
hold received TANF, Food Assistance or Indian Commodities
in Nevada or any other state?
YES NO
If “YES”, who? What benefits
?
Where? Last month and year benefits were received
I certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability. I swear I have honestly
reported the citizenship of myself and anyone I am applying for.
Your Signature Date
FOR OFFICE USE ONLY – EXPEDITED SERVICE SCREENING: HOUSEHOLD ELIGIBLE FOR EXPEDITED SERVICE?
YES NO Expedited service screener signature: ________________________________________ DATE: __________________
4
FOOD & TANF
________________________________________________________
____________________________________
FOOD & TANF
NO
( )
-
___________________________________________ ________ ( ) _______________
____________________________________________________________________________________________
NO
( ) -
FOOD & TANF
/
NO
NO
/
/
/
/
g
________________________________
___________________________________________
5
SPECIAL ACCOMMODATIONS
To get SNAP (food assistance) and/or TANF (cash assistance), most people are required to come into the office for a face-to-face
interview; you need to bring identification with you.
Do you have a physical or mental condition that requires special accommodations during your interview?
YES
NO
If “YES”, what do y
ou need?
(Most services are free to you.)
Do you speak English? YES NO If NO, what language do you speak?
Do you need an interpreter for your interview? YES NO (This service is free to you.)
AUTHORIZED REPRESENTATIVE
AREP
You have the right to assign up to two individuals to act on your behalf either to apply for benefits or to use your benefits for the
household.
7. Do you want someone other than yourself, age 18 or older, to apply for benefits or act on your behalf? YES
If “YES” who? Age? Telephone #
Address
Is this individual currently serving a disqualification for an Intentional Program Violation? YES NO
Do you want an additional person to apply for benefits or act on your behalf? YES NO
If “YES”, who? Age? Telephone#
Address
Is this individual currently serving a disqualification for an Intentional Program Violation? YES
8. In case of emergency, who would you like us to contact? Name Relationship
Daytime Telephone # Address
ADDITIONAL HOUSEHOLD INFORMATION
9. Do you plan to continue living in Nevada? YES NO
If “NO”, explain:
10. List the most recent date you started living in Nevada.
(MM/YYYY)
11. Are you or any person(s) in your household a member of an American Indian or Alaskan Native Tribe? YES
If “YES,” who? What tribe?
12. Are you or any person(s) in your household currently disqualified for an Intentional Program
Violation (IPV)?
YES
If “YES”, who? What state?
13.
a. Have you or any person(s) in your household been convicted of a felony under Federal or State law for
possession, use or distribution of a controlled drug substance (felony drug conviction) after August 22, 1996?
YES NO
If “YES”, who? When? Where?
b. Have you or any person(s) in your household been convicted of trading SNAP ben efits for drugs after
September 22, 1996?
YES NO
If “YES”, who? When? Where?
c. Have you or any person(s) in your household been convicted of buying or selling SNAP benef its over
$500 after September 22, 1996?
YES NO
If “YES”, who? When? Where?
d. Have you or any person(s) in your household been convicted of fraudulently receiving duplicate SNAP
benefits in any State after September 22, 1996?
YES NO
If “YES”, who? When? Where?
e. Have you or any person(s) in your household been convicted of trading SNAP ben efits for guns,
ammunition or explosives after September 22, 1996?
YES NO
If “YES”, Who? When? Where?
14. Are you or any person(s) in your household currently participating in or have participated in a Drug
Addiction or Alcohol Treatment Program?
YES NO
If “YES”, who? Date entered Date completed
Facility Name: Facility Address
15. Are you or any person(s) in your household hiding or running from the law to avoid prosecution, bein
taken into custody, or going to jail for a felony crime or attempted felony crime, or violating a
condition of parole or probation?
YES NO
If “YES”, who? Why?
FOOD & TANF
FOOD & TANF
FOOD & TANF
PREGNANCY
PREG
16. Are you or any person(s) in your household pregnant?
/
/
If “YES”, who?
NO
/
/
/
/
/
/
________________
_____________________
___________________
_____________________
_____________________
___________________
/
____________________________________________________________________________________
____________________________________________________
____________________________________________________________________________________________________
/
/
____________________________________________________
____________________________________________________________________________________________________
/
/
/
/
( ) -
$
/
/
/
/
( ) -
6
Expected due date? (MM/DD/YYYY)
NO YES
DISABILITY
DISA
17. Are you or any person(s) in your household blind, disabled or unable to work due to illness or injury? YES
If “YES”, who? When did this condition begin? (MM/DD/YYYY)
What is the disability?
NON-CITIZEN INFORMATION
ALIE
18. Are you or any person(s) in your household NOT a U.S. Citizen? YES NO
If “YES”, who? Alien Registration #
When did this person enter the United States? (MM/DD/YYYY)
If “YES”, who? Alien Registration #
When did this person enter the United States? (MM/DD/YYYY)
SCHOOL ATTENDANCE (TANF)
SCHL
19.
a. Are you or any person(s) in your household between the ages of 7 and 11 or over 16 attending school?
YES NO
If “YES”, who? School name?
If additional persons “YES”, who? School name?
SCHOOL ATTENDANCE (FOOD)
SCHL/EDIN
b. Are you or any person(s) in your home between the ages of 18 and 49 attending school above the
high school level?
YES NO
If “YES”, who? School name? Hours per week?
If additional persons “YES”?
Who?
School name? Hours per week?
EARNED INCOME/WORK HISTORY
JINC/SELF/OINC/QUIT/STRK
20. Are you or any person(s) in your household currently working, including self-employment? YES NO
If “YES”, who is employed? Hourly wage? $ Hours worked per week?
How often are they paid? Tips paid per month? $
Start date?
Employer’s name? Employer’s telephone?
Employer’s address?
If self-employed, please list any business related expenses.
If “YES”, for additional household members:
Who is employed? Hourly wage? $ Hours worked per week?
How often are they paid? Tips paid per month? $
Start date?
Employer’s name? Employer’s telephone?
Employer’s address?
If self-employed, please list any business related expenses.
If more than two persons are currently working, please attach an additional sheet of paper.
21. Have you or any persons(s) in your household had a job that ended in the last 60 days? YES NO
Who was employed? Hourly wage? $ Hours worked per week?
How often were they paid? Tips received per month? $
Employer’s name? Start date? When did the job end?
Employer’s address Employer’s telephone?
Reason for leaving? Quit Fired Leave of Absence Applied Worker’s Compensation Other
If “YES” for additional household members:
Who was employed? Hourly wage? $ Hours worked per week?
How often where they paid? Tips received per month?
Employer’s name? Start date? When did the job end?
Employer’s address Employer’s telephone?
Reason for leaving? Quit Fired Leave of Absence Applied Worker’s Compensation Other
FOOD & TANF
$
22. Are you or any person(s) in your household currently registered with or working for a temporary employment
service/agency? YES
FOOD & TANF
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
____________________________
$
7
NO
If “YES”, who?
Which service/agency?
23. Are you or any person(s) in your household currently on strike? YES NO
If “YES”, who?
24. Do you or any person(s) in your household work in exchange for food, shelter or something else? YES NO
If “YES”, who? What do they receive for their work?
What is the value of this exchange? $ When did this begin?
UNEARNED/OTHER INCOME
UNIN/GAGA/LSUM/RINC/RBIN/EDIN
25. Please check the “YES” box for each of the types of the unearned income you or any person(s) in your household receives or
has applied for. If you do not check the “yes” box for any of the unearned income below you are acknowledging neither you
or any person(s) in your household have any unearned or other income.
YES SOURCE Person Applied/Receiving Gross Amount Per Month
Alimony
Boarder/Roomer Income
Child Support (Voluntary or Court Ordered)
Contributions/Gifts
Educational Assistance/Student Loans
Foster Care
General Assistance
Insurance Settlements
Interest/Dividends
Loans
Military Allotment
Mining Claims
Panhandling
Pensions/Retirement
Property Rentals
Railroad Retirement
Royalties
Social Security Benefits (RSDI)
Strike Benefits
Subsidized Housing
Supplemental Security Income (SSI)
Supported Living Arrangement (SLA)
TANF Assistance
Trust Income
Unemployment Insurance
Utility Allowance/Rebate Check
Veteran’s Benefits
Gambling Winnings
Worker’s Compensation or Temporary
Disability
Other: (please list)
FOOD & TANF
INCOME MANAGEMENT
26. If you do not have any income, please explain how you are paying your bills and buying personal items for your household?
FOOD & TANF
RESOURCES
BANK/LIFE/PROP
27. Please mark the “YES” box for each types of resources you or any person(s) in your household has, even if jointly owned with
someone outside the household. If you do not check the “YES” box for any of the resources below you are acknowledging
neither you or any person(s) in your household have any resources:
BANK ACCOUNTS
ACCOUNT
YES
NUMBER
TYPE OF ACCOUNT OWNER(S) NAME OF BANK VALUE
(Please list the
last 4 numbers
only)
Savings Account
$
Checking Account
$
Credit Union Account
$
Minor Savings
$
Business Account
$
Christmas Club
Account
$
Educational Savings
Account
$
Patient Trust Fund
$
Individual Indian
Money Account
$
LIFE INSURANCE/TRUSTS/BURIALS
POLICY OR
YES
ACCOUNT
NAME OF COMPANY
TYPE OF ACCOUNT OWNER(S) FACE VALUE
NUMBER
OR BANK
(Please list the last
4 numbers only)
Life Insurance
$ /CSV$
Available Trusts
$
Unavailable Trusts
$
Burial Funds/Plans
$ /CSV$
Life Estates
FOOD & TANF
8
RESOURCES (CONT)
INVESTMENT & RETIREMENT ACCOUNTS
BANK/LIFE/PROP
ACCOUNT
YES
NUMBER
NAME OF BANK OR
TYPE OF ACCOUNT OWNER(S) VALUE
(Please list the
COMPANY
last 4 numbers
only)
Savings Bonds
Stocks or Bonds
Certificates of Deposit
Individual Retirement
Accounts (IRA)
Keogh Account
(401K
)
Annuities
PERSONAL PROPERTY
CURRENT
YES
CONTENTS OR TYPE OF OR
TYPE OF PROPERTY OWNER(S) LOCATION
RESOURCE MARKET
VALUE
Safe Deposit Box
$
$
$
$
$
$
$
$
$
FOOD & TANF
$
$
$
$
$
$
FOOD
$
FOOD
$_______________
_________________________
( )
-
$
$
9
Livestock
Land Mineral Rights
Mining Claims
Business Equipment/
Inventory
Houses/Land or
Buildings
Is this property currently
for sale? Yes No
MISCELLANEOUS
YES
TYPE OF RESOURCE OWNER(S) CURRENT VALUE
Promissory Notes
Cash on Hand
Other: (
please list)
28. Are any of the resources in question 27 designated as money for burial? YES NO
If “YES”, which resources?
VEHICLES
CARS
29. Do you or any person(s) in your household own, or are they buying, a car, motorcycle, trailer, truck, camper, boat,
ATV, etc.? (Please include any vehicles that are not currently working.) YES NO
If “YES”, please complete the information below.
TYPE OF YEAR, MAKE & IS THE VEHICLE FAIR MARKET AMOUNT
OWNER
VEHICLE MODEL REGISTERED VALUE OWED
YES NO
YES NO
YES NO
TRANSFERRED RESOURCE
TRAN
30. Have you or any person(s) in your household sold, traded or given away any money, vehicles, property or other resources, or
closed any bank accounts in the last 3 months? YES NO
If “YES”, who? What resource was transferred?
When? (MM/YYYY) What was the value of this resource when it was transferred?
Who was the resource transferred to? Relationship to you?
Why was the resource transferred?
HOUSING EXPENSES
RENT/HOME/UTIL
31. Please choose which of the following housing costs that you or any person(s) in your household pays.
RENT MORTGAGE/RELATED EXPENSES NONE
32. If you are renting your home, how much is the monthly rent? (Including space/lot rent)
33. What is your landlord’s name? Landlor
d’s telephone number?
34. What
is your landlord’s address?
35. Is your rent subsidized by any agency? YES
NO
36. If “YES,” by which agency? How much is subsidized?
37. If you are buying your home, please complete the areas with the current expenses:
Mortgage Amount (including second) How Often Paid?
Taxes
(if paid separately) $ How Often Paid?
Homeowners Insurance
(if paid separately) $ How Often Paid?
Association Fees
(if paid separately) $ How Often Paid?
Lot/Space Rent $ How Often Paid?
FOOD & TANF
38. Does anyone outside the home pay any of your rent or mortgage expenses? YES NO
If “YES”, who? Telephone? How much? $ How often?
39. Are you or any person(s) in your household responsible for paying any utility expenses? YES NO
If “YES”, does this utility expens
e include costs for heating or cooling? YES NO
If “NO”, please choose the utilities your household is responsible for paying:
Electricity Wood Wat
er Sewer Other
Natural Gas Propane Garbage Telephone
40.
a. Does anyone outside your household pay a portion of your utility expenses? YES NO
If “YES”, w
ho? Telephone? How much? $ How often?
b. Does your household receive or expect to receive assistance from the Energy Assistance Program? YES
NO
OTHER EXPENSES
SUDE/MEDX/DCEX
41. Do you or any person(s) in your household pay court ordered child support to someone outside the household? YES NO
If “YES”, who? How much do they pay per month? $
42. Do you or any person(s) in your household pay child care or for the care of a disabled adult? YES NO
If “YES”, who? For whom?
How much per month? $
43. Does any agency or anyone outside your home pay a portion of your daycare costs? YES NO
If “YES”, who? How much per month? $
44. Does anyone age 60 or over, or any person(s) who is disabled have out-of-pocket medical expenses
including costs for Medicare or medical insur
ance? YES NO
If “YES”, who? How much per month? $
45. Does anyone outside the household pay for any of these medical expenses? YES NO
If “YES”, who? How much per month? $
INJURIES/ACCIDENTS
SETT
46. Have you or anyone in your household been injured or in an accident in the last 12 months? YES NO
If “YES”, who? When?
47. Is there a pending lawsuit because of the injury or accident? YES
NO
If “YES”, what is the attorney’s name?
Attorney’s address?
48. Have
you or anyone in your
household received or expect to receiv
e an insurance reimbursement, payment or
legal settlement?
YES NO
If “YES”, who? when? How much $ From where?
ABSENT PARENT INFORMATION
NCPM
49. Is the parent(s) of the child(ren) you are applying for: (Check one) living somewhere else disabled or deceased
50. If anyone in your home is pr
egnant, is the father of the unborn in the home? YES NO
If “YES”, who is the father?
TANF
TANF
Complete the following form with information about the absent parent of your child(ren) who is not living with you (including
the parent of an unborn child). If there is more than one possible parent, complete a form for each one. Please provide as much
information as possible.
*Please make copies or request additional copies of this page for additional parents.
10
______________________________________________________
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
NON-CUSTODIAL PARENT (NCP) FORM
When applying for TANF the law requires you to cooperate with Child Support Enforcement (CSE) to establish paternity to
get child support owed to you and/or any child(ren) that you are applying for. This may include genetic testing. If the test
proves the person you named is not the father, you may be required to pay the cost of the test. You are also responsible for
providing all available information requested by the CSE Program such as certified copies of divorce decrees and/or support
orders, birth certificates and photographs of the absent parent.
The CSE Program locates absent parents and/or sources of income and assets, establishes and enforces financial support,
reviews and adjusts existing child support orders, and collects and distributes financial payments.
The CSE Program has sole discretion in determining which legal remedies are used in pursuing support and cannot guarantee
success. CSE may request assistance of another state, and thereby, be subject to the laws of that state. CSE does not provide
services involving custody or visitation. CSE may close your case when your case meets closure rules established by federal
and state regulation.
The CSE Program represents the State of Nevada when providing services and no attorney-client privilege exists. CSE is
authorized to endorse and cash payments made payable to you for support payments and may collect past-due support by
intercepting an IRS tax refund or other federal payment. If a tax intercept occurs, the CSE Program has the authority to hold
a joint tax refund for a period of six (6) months before distributing the funds. No interest is paid on the held funds. Funds
collected from a tax intercept are applied first to pay off any past-due support assigned to the State of Nevada. A
nonrefundable fee is deducted by the federal government of any tax or federal payment intercepted by the CSE Program.
Good cause for not cooperating in pursuing child support or paternity may be allowed. If you do not cooperate with CSE
and good cause has not been determined, your household will be ineligible for TANF. Good cause for not cooperating will
be considered if you request it in writing. Examples of good cause are as follows:
● The child was conceived as a result of rape or incest.
● Legal proceedings for adoption of the child are pending before a court.
● You are being assisted by a public or licensed private social service agency to decide whether to keep or
relinquish the child for adoption (no longer than three (3) months).
● Your cooperation in establishing paternity or securing support will result in physical or emotional harm to
yourself or the child(ren).
You must provide your case manager with verification within twenty (20) days after claiming good cause. You will receive
written notification of the good cause decision. If you are found to have good cause for not cooperating, CSE will NOT
attempt to establish paternity or collect child support.
YE
S,
I wish to claim good cause.
NO, I am not claiming good cause at
t
his time.
Signature
You must
report
chang
es
whenever
a name change occurs;
you have a new address
or
telephone number
for
home or
work;
you hire a private attorney
or
collection agency;
another
child support
or
paternity
legal
action is filed;
you file for
divorce;
you receive support
payments directly
from
the absent
parent;
you have a new address, telephone number, employment
for
the
absent
parent;
a
child(ren)
no longer
lives
with you;
a child(ren)
is still
in
high school
after
age 18;
a
child(ren)
becomes
disabled
before age 18;
a child(ren)
comes
to live with you or
you birth
another
child;
a child marries, is adopted,
joins
the
armed forces or is declared an adult by court
order.
You are responsible for
repayment
of
support
amounts
received in error, including
payments from
an IRS tax refund, which
are adjusted by
the IRS.
If
you fail
to enter
into a repayment
agreement
with
the CSE
Program, the outstanding
balance
may
be reported to a
credit
reporting
agency
and money
collected
on your
behalf
by
the CSE
Program
may
be withheld
for
repayment. Additionally, legal action may be initiated against you.
11
NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES
NON-CUSTODIAL PARENT (NCP) FORM
Complete one form for each parent who does not live with the child(ren) for whom you are requesting assistance. For
example, if you have two children and each have a different father / mother, you need to complete two forms. If you
are not the parent of the child(ren) you are requesting assistance for, you need to complete one form for the absent
mother and one form for the absent father. Do not leave any question blank. Write or type unknown or N/A (not
applicable) for any question that does not apply or you do not know the answer.
YOUR NAME: YOUR SSN: YOUR DOB: YOUR RELATIONSHIP TO THE
CHILD(REN):
Have you or the children received public
assistance in the past? YES NO
If YES, where? (City, State)
Fill in whatever you know about the Non-Custodial Parent. If you do not know the answer to the question, write unk
nown or N/A.
LAST NAME: FIRST NAME: MIDDLE INITIAL: MODIFIER (Jr., Sr., etc.):
ADDRESS:
CITY: STATE: ZIP:
SOCIAL SECURITY NUMBER: TELEPHONE / CELL PHONE:
DATE OF BIRTH:
BIRTH CITY AND STATE:
IF DECEASED, DATE OF DEATH: IF DECEASED, PLACE OF
DEATH:
YES
DATE LAST SEEN OR CONTACTED:
IS HE OR SHE DISABLED? NO
RACE: SEX: HAIR COLOR: EYE COLOR: WEIGHT: HEIGHT:
AT ANY TIME WAS THE MOTHER MARRIED TO
THIS NON-CUSTODIAL PARENT? YES NO
DATE OF MARRIAGE: PLACE OF MARRIAGE:
IF MARRIED ARE THEY DIVORCED? YES NO
DATE OF DIVORCE: PLACE DIVORCE FILED:
WAS THE MOTHER MARRIED TO
SOMEONE ELSE? YES NO
ARE THERE OTHER POSSIBLE
FATHERS? YES NO
EXISTING CHILD SUPP
ORT COURT ORDER? YES NO CITY AND STATE:
INFORMATION ON THE CHILDREN FOR THIS ABSENT PARENT:
Child’s
Social Security
Number
Child’s Last Name Child’s First Name
C
hild’s
Middle
Initial
Child’s date
of birth
(MM/DD/YY)
Did the mother have
sexual relations with
another man (not
named above), during
30 days before or
after when pregnancy
began for this child?
YES NO
Custody
Month
YES NO
YES
NO
All cases for Temporary Assistance for Needy Families (TANF) must be referred for Child Support Enforcement. This
information is correct to the best of my knowledge. I have read the “Important Child Support Information” section found on the
eligibility application. I understand if I have intentionally withheld or misrepresented information, I could be disqualified from
receiving public assistance.
I declare under penalty of perjury that the information I have provided on this document is true to the best of my knowledge and
belief and that the statements contained herein are made for the purposes stated here, including but not limited to, obtaining
assistance in establishing paternity and/or an order for child support along with the collection of child support.
Your Signature: Date Signed:
12
____________
Important Child Support Information
By signing this application and by receiving TANF benefits, you agree to assign your child support rights to the State of Nevada
Division of Welfare and Supportive Services (DWSS). This is a condition of eligibility for your household to receive TANF
benefits. If you are receiving TANF, any court ordered or stipulated child support paid directly to you is required by law to be
surrendered immediately to DWSS or Child Support Enforcement (CSE). By signing this application, you are authorizing DWSS
to transfer all or part of the support collected each month to pay back the TANF benefits your household received.
When applying for TANF, the law requires you to cooperate with CSE to establish paternity to get child support owed to you
and/or any child(ren) for which you are applying. Good cause for not cooperating in pursuing child support or paternity may be
allowed. If you do not cooperate with Child Support Enforcement and good cause is not established, your household will be
ineligible for TANF.
If TANF is terminated and child support is collected, any portion due to you will be made as a direct deposit onto a Nevada Debit
Card or into your bank account. A Nevada Debit Card will be issued to you unless you request payments by direct deposit into
your bank account. Visit our website: dwss.nv.gov for more information.
You are responsible for repayment of child support amounts received in error, including child support payments from an IRS tax
refund which are adjusted by the IRS. If you fail to enter into a repayment agreement with the CSE program, money collected on
your behalf by the CSE program may be withheld for repayment and the outstanding balance may be reported to a collection
agency.
DWSS may charge a $25.00 fee for child support services provided to clients who have never received public assistance.
Do you wish to pursue child support if your household is found ineligible for TANF?
Yes No
______________
13
Init
ials
Electronic Benefits Transfer (EBT)
Federal law states the intended per
iod of use for SNAP benefits is 12 months from the date of issuance. DWSS is required to
remove any unused SNAP benefits from an account 365 days after the benefit was issued and return them to the Federal
government. Unused benefits are frozen 360 days after their issuance. If the client, or any adult member of the client’s household,
has any outstanding SNAP d ebt, the frozen benefit will be applied towards the SNAP debt.
Unused TANF benefits are removed from a client’s EBT account 180 days after the benefit was issued.
Per Federal Law, TANF EBT benefits cannot be accessed from ATM machines or used to purchase items in the following
locations: casinos, gaming establishments, liquor stores or retail establishments which provide adult entertainment.
It is illegal to misuse, sell, attempt to sell, trade, purchase or alter an EBT card.
Initials
Work Requirements
If you are approved for TANF and/or SNAP, you may be required to cooperate with certain work requirements. Failure to comply
with certain work requirements could disqualify you and/or other members of your household from participating in either program.
For SNAP, if you or any other household member voluntarily quits a job or reduces work hours without good cause, this may be
considered failure to comply with work requirements. The SNAP disqualification period for failure to comply with work
requirements is one month and until compliance for the first violation, three months and until compliance for the second violation,
and six months and until compliance for the third violation. For TANF, failure to cooperate with work requirements agreed to in
their Personal Responsibility Plan may result in the household losing their TANF benefits for three full months.
Reviews and Investigations
By signing thi
s application, you are authorizing the Department of Health and Human Services to make investigations concerning
you, other members of your household, and/or your child(ren)’s legal or natural parent(s) that may be necessary to determine
eligibility for benefits you or your household receives or will receive under programs administered by the DWSS, including
childcare assistance. Information provided to the DWSS may be verified or investigated by federal, state and local officials
including Quality Control staff. If you do not cooperate in the investigation, your benefits may be denied or terminated. If
you make false or misleading statements, misrepresent, conceal or withhold facts necessary for the DWSS to make an
accurate determination on your benefits or alter any document, your benefits may be denied, reduced or terminated. You
are responsible for repayment of all monies, services and benefits (including childcare assistance) for which you were not entitled
to. Additionally, you may be disqualified from receiving benefits in the future and criminally prosecuted or otherwise penalized
according to state and federal law.
____________
Initials ___________
__________
Initials ____________
Individuals found guilty of an intentional program violation in TANF and/or SNAP are barred from program benefits for
twelve (12) months for the first violation, twenty-four (24) months for a second violation and PERMANENTLY for the
third violation. The unlawful use of SNAP is punishable by a fine up to $250,000, imprisonment for up to 20 years or both.
If a court of law finds you guilty of using or receiving SNAP benefits in a transaction involving the sale of a controlled
substance, you will not be eligible for benefits for two years for the first offense, and permanently for the second offense.
If a court of law finds you guilty of having used or received SNAP benefits in a transaction involving the sale of firearms,
ammunition or explosives, you will be permanently ineligible to participate in the Program upon the first occasion of such
violation.
If a court of law finds you guilty of having trafficked SNAP benefits for an aggregate amount of $500 or more, you will be
permanently ineligible to participate in the Program upon the first occasion of such violation.
If you are found to have made a fraudulent statement or representation with respect to the identity or place of residence in
order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the Program for a period of
10 years.
14
Initials
Your Rights
Anyone whose application for assistance has been denied, not acted on within a reasonable time frame, or whose benefits have
been reduced or terminated may request a conference or hearing. You may request a conference or hearing by writing your local
district office or the administration office. For SNAP, you may request a hearing by calling your local district office. You may
also request a hearing by signing and returning the Notice of Decision you receive. You must request a hearing for TANF or
SNAP within 90 days of the notice date.
You will be notified of the hearing date, time and location in writing ten (10) days prior to the scheduled hearing. You may be
represented at a conference/hearing by anyone whom you have given written authorization. This written authorization must be
given to the DWSS office prior to the conference/hearing. You may request information on the various legal services that may be
available in your community at no cost; please contact us for information. If you are dissatisfied with the hearing decision, you
may appeal your case to your local District Court of the State of Nevada.
Important Information
If you are appl
ying for TANF and SNAP with this application and your TANF benefits are approved, any adjustment to your
SNAP benefits will be made at the same time. With this application, you are waiving your right to 13 days advance notice of any
change in your SNAP benefits resulting from TANF approval. If your TANF benefit is less than $10.00, you will receive no cash
payment.
The DWSS may mail information to you that may require you to respond by a certain date. If you are away from home, you are still
responsible to respond by the required date. You may wish to make arrangements for your mail while you are away.
Your Responsibilities
If you are applying for TANF:
You must r
eport changes in your mailing address immediately. Additional changes must be reported immediately after you apply
and before you are approved benefits. Once your benefits are approved you must report the following changes and the change must
th
be reported by the 5 of the following month. You must report changes such as your physical address, living expenses, subsidized
housing value, marital status, employment status, any money you receive or income from any source, assets/resources, absent
parent’s address, number of people in the home, the birth of a child, school attendance, absence of any household member even if it
is temporary (if more than 30 days), and any other change which may affect your household benefits.
Initials
Your Responsibilities
If you are applying for Supplemental Nutrition Assistance Program (SNAP):
You are required to report all changes in your household from the date you submit your application to the day of your interview.
Once SNAP benefits are approved, you must report required changes within 10 days from the date the change happened based on
your household’s specific reporting requirements. You will receive a notice informing you of your specific requirement.
If your household is designated as a Change Status Reporting Household you will be required to report changes such as your
physical address, living expenses, subsidized housing value, marital status, employment status, any money you receive or income
from any source, assets/resources, number of people in the home, birth of a child in your home, school attendance, absence of any
household member even if it is temporary (if more than 30 days), and any other change which may affect your household benefits.
If your household is designated as a Simplified Reporting Household you must only report when your household’s income exceeds
130% of the federal poverty level for your household size. If SNAP benefits are approved you will be notified of the income level
for your household size.
Your case manager may request additional proof of the change. You will be required to provide the proof by a certain date in order
to continue your eligibility or to avoid an overpayment or underpayment of benefits.
SNAP allows certain household expenses like rent, mortgage, property taxes, homeowner’s insurance, utility expenses,
child/dependent care and child support paid by the household as a deduction to determine the amount of SNAP benefits your
household is eligible for as long as the expense is reported and verified. Medical expenses over $35.00 are allowed if there is an
elderly (age 60 or over) or disabled person applying for benefits. If you do not report or verify any of the expenses listed on the
application, it will be considered that you do not want to receive a deduction for the unreported or unverified expense
.
Initials
____________
Initials ____________
15
16
Blank page
Release of Information
I hereby authorize and consent to the release of all information concerning me or my household members to the
Department of Health and Human Services by the holder of the information such as, but not limited to, wage
information, information made confidential by law, as well as patient information privileged under NRS 49.225, or
any other provision of law. I hereby release the holder of the information from liability, if any, resulting from the
release (disclosure) of the required information.
If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my right as an older
person to have my identity kept confidential. I hereby release the holder of information from liability, if any,
resulting from the disclosure of the required information.
Initials
____________
I understand if I fail to initial pages 12-14 where indicated on this application, it does not release me or my
household members from those requirements / obligations. If I am under age 18 and applying for TANF
assistance I understand I must have an additional signature of an adult over age 18 to complete the application.
I understand the questions on this application and the penalty for hiding or giving false information. I agree to
notify the Nevada State Division of Welfare and Supportive Services of any changes in my household
circumstances that may affect my benefits. I understand failure to report changes may cause an overpayment
that I would be responsible to pay back and could even be prosecuted by a court of law. I certify under penalty
of perjury, my answers are correct and complete to the best of my knowledge and ability. I swear I have
honestly reported the citizenship of myself and anyone I am applying for.
Signature or Mark of Applicant
____________________________________________________________________________________________________
17
Date Signature or Mark of Spouse/
Second Parent of Child(ren)/Adult Representative
Date
Witness: (Use if applicant cannot read or write or is blind.)
The information in this application has been read to the
applicant and I have witnessed the above signature.
Signature of Witness Date
Your completed application may
be submitted to your local Welfare office or mailed to PO Box 15400, Las Vegas, NV 89
114.
IF YOU ARE NOT REGISTERED TO
VOTE WHERE YOU LIVE NOW,
WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?
(Please check one)
YES NO
If you do not check either box, you will be considered to have decided not to register to vote at this time.
The NATIONAL VOTER RE
GISTRATION ACT provides you with the opportunity to register to vote at this location. If you
would like help in filling out a voter registration application form, we will help you. The decision whether to seek or accept help is
yours. You may fill out the application form in private.
IMPORTANT NOTICE: Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance you
will be provided by this agency.
Signature Date
CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential.
IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or your right to
choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State,
Capitol Complex, Carson City, Nevada 89701.
18
Blank page
click to sign
signature
click to edit
Your Rights
Anyone whose application for assistance has been denied, not acted on within a reasonable time frame, or whose benefits have been
reduced or terminated, may request a conference or hearing. You may request a conference or hearing by writing your local district
DWSS office or the administration office. For SNAP, you may request a hearing by calling your local district DWSS office. You
may also request a hearing for assistance programs such as TANF or SNAP within 90 days of the notice date. You will be notified in
writing 10 days prior to the hearing date, the time and location of the hearing. You may be represented at a conference/hearing by
anyone you have given written authorization to which must be given to the DWSS office prior to the conference/hearing. You may
request information on the various legal services which may be available in your community at no cost, please contact us for
information. If you are dissatisfied with the hearing decision, you may appeal your case to your local District Court of the State of
Nevada.
Your Responsibilities
If you are applying for TANF:
You must report changes in your mailing address immediately. Additional changes must be reported immediately after you apply and
before you are approved benefits. Once your benefits are approved you must report the following changes and the change must be
reported by the 5
th
of the following month. You must report changes such as your physical address, living expenses, subsidized
housing value, marital status, employment status, any money you receive or income from any source, assets/resources, absent parent’s
address, number of people in the home, birth of a child in your home, school attendance, absence of any household member even if it
is temporary (if more than 30 days), and any other change which may affect your household benefits.
If you are a
pplying for Supplemental Nutrition Assistance Program (SNAP):
You are required to report all changes in your household from the date you submit your application to the day of your interview.
Once SNAP benefits are approved, you must report required changes within 10 days from the date the change happened based on your
household’s specific reporting requirements. You will receive a notice informing you of your specific requirement.
If your household is designated as a Change Status Reporting Household you will be required to report the same changes listed under
the TANF reporting requirements listed above.
If your household is designated as a Simplified Reporting Household you must only report when your household’s income exceeds
130% of the federal poverty level for your household size. Your household will be notified of this amount at approval.
Your case manager may request additional proof of the change. You will be required to provide the proof by a certain date in order to
continue your eligibility or to avoid an overpayment or underpayment of benefits.
The Supplemental Nutrition Assistance Program allows certain household expenses like rent, mortgage, property taxes, homeowner’s
insurance, utility expenses, child/dependent care and child support paid by the household as a deduction to determine the amount of
SNAP benefits your household is eligible for as long as the expense is reported and verified. Medical expenses over $35.00 are
allowed if there is an elderly or disabled person applying for benefits. If you do not report or verify any of the expenses listed on
the application, it will be considered that you do not want to receive a deduction for the unreported or unverified expense.
Utilizing T
ANF funds, DWSS through the Nevada Public Health Foundation (NPHF), has developed a class to target pregnant and
parenting teens receiving TANF cash assistance. Teen parents receiving TANF benefits and services are known as STARS
(Supporting Teens Achieving Real-life Success) participants. This class has been expanded to include other pregnant and parenting
teens receiving other forms of assistance such as SNAP and Child Welfare. This one-day class places emphasis on employment,
success in the workplace, decision-making, money management and health, such as birth control and sexually transmitted diseases.
In addition, Community Action Teams, an entity of the Nevada Public Health Foundation, conduct community assessments of teen
pregnancy and its prevention and identify potential methods for reducing teen pregnancy through abstinence-based programs. Youths,
parents, business, churches, health care providers, law enforcement, schools and other organizations are encouraged to serve on the
Community Action Teams. Men of all ages are also encouraged to serve as positive role models, reinforcing the postponement of
sexual involvement message.
After you submit your application you may call our Voice Response Unit (VRU) system to find out if your case has been approved,
denied, terminated or is still pending. The VRU system will also let you know when your benefits have been issued and the amount.
For Southern Nevada, call (702) 486-1646; Northern Nevada, call (775) 684-7200; Rural Nevada, call (800) 992-0900, extension
47200. Your Personal Identification Number (PIN) for the VRU system is ___________________.
You may contact your case manager _____________________at _________________between the hours of ________ to
Visit our website at http://dwss.nv.gov/
This is Your Copy, Keep This Page for Your Records
19
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