Fillable TANF MEDICAID SNAP STATE OF NEVADA DEPARTMENT OF (State of Nevada, Department of Information Technology)

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TANF MEDICAID SNAP STATE OF NEVADA DEPARTMENT OF (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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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
2074 - EG-B (215.0.0)
Page 1 of 2
TANF MEDICAID SNAP
Date:
Case Name:
Case ID:
EMPLOYER PAYROLL STATEMENT
Please list below all monies (earnings, sick pay, vacation pay, disablility, etc.) PAID OR ANTICIPATED TO BE PAID
(regardless of when earned) to client OR provide a printout of wages for same period IN:
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
2074 - EG-B (215.0.0)
Page 2 of 2
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
For: (Month/Year)
Pay Period
Ending
Date Pay
Received
No. of
Hours
Worked Gross
Tips (Not
Included
in Gross)
Signature Print Name Title Date Telephone Number
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TANF MEDICAID SNAP STATE OF NEVADA DEPARTMENT OF (State of Nevada, Department of Information Technology)

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Completed 28 September 2020

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