The Nevada Division Welfare form is an application used to request assistance through various public programs, including Medicaid and the Supplemental Nutrition Assistance Program (SNAP). This form is essential for individuals seeking medical assistance or food support in Nevada. If you need help completing the form, don’t hesitate to reach out for assistance.
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State of Nevada
Department of Health and Human Services
Division of Welfare and Supportive Services
APPLICATION FOR ASSISTANCE
MEDICAID - MEDICAL ASSISTANCE TO THE AGED, BLIND AND DISABLED (MAABD)
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, LET US KNOW.
Public Assistance Programs you may apply for:
MEDICAID - Medical Assistance to the Aged, Blind and Disabled (MAABD)
Medical assistance for low-income individuals who are eligible under the following programs:
●Over Age 65
●Blind
●Disabled
●Hospital Stay, Nursing Home Stay, Home Care Waiver Application
●Non-citizens Who Meet Specific Program Requirements
●Qualified Medicare Beneficiaries
Food assistance (formerly known as Food Stamps) for low-income households to help supplement the purchase of food.
READ THIS PAGE CAREFULLY BEFORE FILLING OUT THE APPLICATION
1.Read each page carefully and answer every question. If the answer is "none," then write in "NONE."
2.If you need help filling out the form, you may want to ask your family, a friend or a case manager from the Division of Welfare and Supportive Services (DWSS).
3.Remember, you are certifying to the correctness of your answers whether you are completing the form yourself, or acting for another person who is unable to complete the form.
The Division of Welfare and Supportive Services will verify the answers you give on this form. Willful concealment of income and assets could result in criminal prosecution.
4.Your Rights and Obligations as a recipient are attached to the back of this application.
5.If you are applying for someone other than yourself, check boxes or complete blank spaces as it applies to the person for whom the application is made.
2920 – EM (3/11)
If you are also applying for SNAP, we must verify information you provide and take action on your SNAP application within 30 days from the date you submit your application.
If you are eligible, SNAP benefits will be provided from the date you give us the first page.
If you qualify to get SNAP right away, we must take action on your SNAP application within 7 days from the date you give us the first page. You may get SNAP right away if:
Monthly rent/mortgage and utilities are more than your household’s gross monthly income; or Gross monthly income is less than $150 and your household’s resources, such as cash or checking/savings accounts, are $100 or less; or
Disclosure of Social Security Numbers: Pursuant to Title 42 USC 1320b-7, Social Security Numbers (SSN) are required for individuals receiving or seeking to receive assistance for themselves. If you or an individual in your household is applying for assistance and do not wish to provide or apply for an SSN, only this person’s request for assistance will be denied. Undocumented or ineligible non-qualified citizens and other non-applicants or ineligible persons are not required to provide or apply for an SSN. Individuals who do not wish to pursue an SSN are considered non-applicants, but their income and resources may still be countable to other household members seeking assistance such as dependent children and/or a spouse. However, if you or an individual in your household is seeking assistance for themselves and meet “good cause” for not providing or pursuing an SSN, assistance may be granted if otherwise eligible.
Social Security Numbers are used to verify your family’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 issued.
Disclosure of Citizenship and/or Immigration Status: You will be required to provide proof of citizenship and/or immigration status. If you or another member of your family or household do not want SNAP benefits, then you/they DO NOT have to give us information about citizenship or immigration status. If you are applying for TANF-cash assistance, Medicaid or SNAP, we may decide that certain members of your family are ineligible for benefits because they do not have the right immigration status. If that happens, other family members may still be able to get benefits if they are otherwise eligible. If you want us to decide whether other family members are eligible for benefits, you will still need to tell us about their citizenship and/or immigration status. You will also need to tell us about your family’s income and answer the other questions on this form.
Non Discrimination: In accordance with Federal law and U.S. Department of Agriculture (USDA) and Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs, “To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.”
Important Notice: If you are applying for a child not eligible for Medicaid assistance on this application, the Nevada
√Check Up Program provides low-cost, comprehensive health care coverage to uninsured children 0-18 years of age who are not covered by private insurance or Medicaid. To find out the eligibility requirements for this medical program or to request an application, go to http://nevadacheckup.nv.gov or call 1-877-543-7669.
Medical benefits start from the first day of the month eligibility is approved, with the exception of some Medicare beneficiaries.
Complete the application questions as they pertain to the person in need of assistance.
If you need more space to answer, write on a separate sheet of paper.
Race (optional) – please check one of the boxes
Hispanic/Latino or
Non-Hispanic or Latino.
Please list below the ethnicity* code for each household member: A – Asian; B – Black or African American;
I – American Indian or Alaska Native; J – American Indian or Alaskan Native and White; L – Asian and White; American and White; N – Native Indian/Alaskan Native and Black/African American; U – Native Hawaiian or other White; Z – 2 or more combinations not listed above.
Please list marital status for each household member: D – Divorced; L – Legally Separated; M – Married; N – Never Married; P – Separated; W – Widowed
M – Black or African Pacific Islander; W –
SOCIAL
SECURITY
NAME
NUMBER
OR ALIEN
REGISTRATION
STATE OR
S
COUNTRY
LAST NAME, FIRST
RELATION
E
(optional see
OF
TO YOU
X
cover page)
BIRTH
self
CITIZEN?
Y/N
U.S.
*RACE/ETHNICITY
DATE
A
G
LAST GRADE COMPLETED
YEAR COMPLETED
MARITAL STATUS
M A A B D
S N A P
N O N E
Facility Address
City
State
Zip
Home Address
Mailing Address
Home Phone
Day/Message Phone
Date of Death (If applicable)
MEMB
SPEC
APPLICANT INFORMATION
AREP
INFC
1.When did the above person(s) move to Nevada? _________________
2. Do you intend to continue living in Nevada?
YES
NO
3.Has anyone, applying for assistance, RECEIVED any type of public assistance in the
past 90 days?
If YES, Who:
Where:
When:
Name of Person
County
Mo/Yr
If you are applying for Medicaid, you may request payment for any medical expenses you had in the three months prior to this medical application. This is known as PRIOR MEDICAL ASSISTANCE.
4. Does anyone wish to apply for prior medical assistance? Months Requested
Who:
5.Has anyone, applying for assistance, been in a hospital, nursing home or other medical
institution during the past 3 months?
Are you currently in a hospital, nursing home, or other medical facility?
Date Entered:
Date Left:
Facility Name/Address:
6.
Are you (check EACH answer that applies to you)
Age 65 or Older
Blind
Disabled
7.
If disabled, date most recent disability began:
What is your disability?
Under penalty of perjury, I swear the statements on this application are true and correct.
_____________________________________________________________________________________________________
Your Signature
Date
PHOTOCOPY AND DATE STAMP PAGE 1 TO ESTABLISH APPLICATION DATE.
1
8.Is any household member a veteran?
Name
Branch of
VA Claim Number
Serial Number
Dates of Service
Service
—
9. Have you worked for a railroad company or for federal, state, county or city government?
If YES, complete below.
Name of employer
Address of employer
Dates you were employed
Claim Number
Identification Number
10.Does any household member have medical benefits through either Medicare (Part A or B)
or Railroad Retirement Coverage? Who
Claim #
11.
Does anyone have any health/dental insurance or is it available to you from any source?
Insurance company name and address:
Policy in name of
Policy owner’s Social Security No.
Group or Policy No.
Effective date of coverage
12.
Has any household member been injured in an accident?
13.
Do you want someone other than yourself to apply for benefits or act on your behalf?
(This would include obtaining and using SNAP for you. This person must be at
least 18 and have I.D.) If YES, complete below.
Address
Telephone Number
Age
RESIDENCE INFORMATION
PROP
14.If you or your spouse reside in a medical facility regardless of medical condition, do you or your
spouse intend to return to your home?
15.
Is this residence occupied by a community spouse, dependent relative or other person?
16.
Do you receive rental income from your home?
17.
What is the fair market value of your home? $
18.
What amount is owed on your home? 1st Mortgage
2nd Mortgage
BANK
CARS
RESO
RESOURCES
LIFE
TRAN
19.List all resources you or a member of your household have, such as: bank/credit union accounts, stocks and bonds, property, life and burial insurance, etc.
Available Trust Funds ______________
Individual Indian Money Accounts (IIM)
Other Account Types
Burial Funds/Plans
Individual Retirement Accounts (IRA)
Other Houses, Land or Buildings
Business Checking Accounts
Keogh Accounts (401K)
Promissory Notes or Contracts
Business Equipment/Inventory
Land/Mineral Rights
Safe Deposit Box
Cash on hand $_____________
Life Estates/Life Leases
Savings Account
Certificates of Deposit (CD)
Life Insurance Policies
Savings Bonds
Checking Accounts
Livestock/Horses
Stocks/Bonds
Christmas Club
Mining Claims
The Home You Live In
Credit Union Accounts
None
Unavailable Trust Funds
Other
2
Owner(s)
Resource
Type
Account/Policy
Number
Amount
Value
Owed
20. Are any of the resources, in question 19, MONEY FOR BURIAL?
If YES, which item(s):
21. List all cars, trucks, recreational vehicles, trailers, etc., for all persons applying for
assistance. INCLUDE VEHICLES THAT DO NOT RUN.
Car
Motorcycle
Motor Home
Trailer/Camper
Truck/Van
Snowmobile
Boats/Motors
Other Vehicle (dune buggy, ATV, etc.) _____________________
Year, Make &
Model
Check if Value Registered
Year, Make
& Model
22.
Has anyone sold, traded, or given away money, vehicles, property or other resources,
closed any bank accounts, or purchased any annuities in the last 60 months?
If YES, give date
Value of property and/or cash gift
Description of property/gift
Total sale price
23.
Have either you or your spouse executed a trust, annuity, court order and/or purchased a
Promissory Note, loan or Life Estate?
Be aware that by virtue of the provision of medical assistance for institutional care, annuities purchased on or after February 8, 2006 must name the State of Nevada as the remainder beneficiary.
If YES, attach a copy(ies) of the document(s) with the application.
JINC
SELF
INCOME INFORMATION
OINC
QUIT
24. List current AND last employer for ALL household members.
How
Tips Per
Employment
Name, Address of Employer
Often
Hours
Hourly
Pay
Dates MM/YY
or Training
Paid
Worked
Wage
Period
Reason for Leaving
Name:
Start:
End:
3
RINC
RBIN
EDIN
UNEARNED INCOME
LSUM
GAGA
UNIN
25.Has anyone in the household applied for or currently receiving any money other
than from a job?
If YES, complete boxes below.
Child Support/Alimony (Absent Parent)
Supplemental Security Income (SSI)
Contributions/Gifts
Native TANF
TANF Assistance
County Assistance/General Assistance
Pan Handling
Temporary Disability Insurance
Educational Assistance
Pensions/Retirement
Tribal Assistance/IGA
Foster Care Payments
Railroad Retirement
Trust Income
Insurance Settlements
Royalties
Unemployment Insurance
Interest/Dividends
Social Security Disability
Utility Allowance From Housing
Loans
Social Security Retirement
Utility Rebate Check
Lump Sum Payments
Social Security Survivor’s
Veterans Benefits
Military Allotment
Strike Benefits
Winnings
Worker’s Compensation
Other:
Income Type
Who Receives
How Often
Amount How Often
SPOUSE INFORMATION
SHST
26.Complete the following on your current and most recent spouse. If spouse is deceased, all possible information must still be completed.
Spouse’s Name
Social Security Number
Date of birth
Date of death
Veteran?
Divorced?
Widowed?
Date:
/
Employer name/address
Medical insurance
Are you covered?
Railroad, federal or local government employee?
RR or gov’t claim number
Years employed
4
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM APPLICATION
COMPLETE THIS PAGE ONLY IF APPLYING FOR SNAP AS HOME BASED WAIVER APPLICANT OR SPOUSE OF APPLICANT REQUESTING HOSPITAL OR NURSING HOME ASSISTANCE.
27.
Do you usually buy and prepare your food with the other people in your home?
28.
What is the TOTAL gross amount of money your household expects to receive
this month from any source?
$
29.
How much do all persons have in cash, checking and savings accounts?
30.
How much is your current monthly cost for housing (rent/mortgage) and utilities?
31.
Has anyone in the household received benefits in another state?
When?
–
City/County/State?
32. Is any household member on strike? If YES, complete below.
Name of Person on Strike
Date Strike Began and Ended
Employer's Name, Address and Phone No.
33. Are there non-citizen members living in the house?
34.Is any member in the household applying for assistance currently wanted by any law enforcement agency for any reason (including questioning)?
35Has any member in the household applying for assistance ever been convicted of any drug-related offenses?
36.Is anyone in the household applying for assistance currently sanctioned for an intentional program violation?
RENT
HOME
SUDE
MEDI
EXPENSES
MINS
UTIL
YES NO
DCEX MEDX
If you claim and provide proof of shelter, utility, dependent care and/or medical expenses, your SNAP amount may be more. If you have any of these expenses and do not claim them and/or do not provide proof, your SNAP benefits may be less than you would receive if expenses were claimed. Failure to claim or provide proof of expenses will be seen as a statement by your household you do not want to receive a deduction from income for the unreported expense.
37.Does anyone in the household pay court ordered child support to
someone not living with you?
NO /Do not wish to claim
38.Is anyone paying for or being charged for the case of a dependent child or disabled adult so someone
in the household can work, attend training, school, or look for work?
NO Amount $__________
39. Does anyone in the household expect any changes in income, expenses or work hours?
40.Were you billed for or expect to pay medical costs (doctor/hospital bills, prescriptions,
dental bills, etc.) for anyone in your home who is disabled or age 60 or older?
41. List the monthly shelter expenses for your household.
Rent or Space Rent
Electricity
Water
Mortgage (including 2nd)
Natural Gas
Garbage
Property Taxes
Propane
Sewer
Home Insurance
Heating Oil
Telephone
Association Fees
Wood
42.
Does anyone else pay a portion of your rent or utilities?
Who?
How much?
43.
Is the rent government subsidized (HUD, Section 8, Federal Public Housing, etc.)?
44.List landlord’s/rental company’s name, address and phone number.
Landlord’s Name
FOR OFFICE USE ONLY - EXPEDITED SERVICE SCREEN - Household eligible for expedited service.
NO Expedited Service Screener’s Signature:
SIGNATURE AND AFFIRMATION
5
Information provided on this form is subject to verification and investigation by federal, state, and local officials. If you make a false or misleading statement, misrepresent, conceal or withhold facts to establish or maintain program eligibility, your benefits may be reduced/denied/terminated. You will be responsible for repayment of all monies, services and benefits for which you were not legitimately entitled.
Individuals found guilty of intentional program violation of SNAP are barred from program participation for twelve (12) months for the first violation, twenty-four (24) months for a second violation and PERMANENTLY for a third violation.
The unlawful use, transfer, acquisition, alteration, or possession of SNAP is punishable by a fine up to $250,000, imprisonment for up to 20 years, or both. You are liable for any over issuance resulting from erroneous information. A court can also bar an individual from the program for an additional 18 months. The person may also be subject to further prosecution under the federal laws.
Qualified non-citizen status will be verified with the Bureau of Citizenship and Immigration Services (BCIS) for eligibility purposes.
I wish payments under the medical insurance program (Part B of Title XVIII) to be made directly to physicians and medical suppliers on any future unpaid bills for medical and other health services furnished me while eligible for welfare assistance.
Eligibility and income information is regularly requested from the Nevada State Employment Security Department, the Social Security Administration and Internal Revenue Service, and is used to determine your eligibility for and amount of assistance.
I hereby assign to the Division of Welfare and Supportive Services, as a condition of eligibility, all rights to medical support or other payments for medical care for myself and all persons for whom I am applying/receiving assistance. I will cooperate with the Division in obtaining third party benefits and/or payments for medical care.
I understand that I have a duty to inform the Division of Welfare and Supportive Services if I, or anyone on my behalf, commence a legal action against someone for recovery of money as reimbursement for medical care and treatment paid by the Medicaid program AND that I must further advise the Division of Welfare and Supportive Services should I, or anyone on my behalf, solicit or receive any offer of settlement of money as reimbursement for medical care and treatment paid for by the Medicaid program. I understand I must surrender any such monies received to the Division of Welfare and Supportive Services.
Medicaid recipients who are: 1) 55 years of age or older; OR 2) inpatients of a medical facility may be responsible for repayment of Medicaid expenditures paid on their behalf. Recovery would be accomplished from the estate of recipient after their death or after the death of their surviving spouse. (See attached Form 6160-AF, Program Operation.)
Any person who signs an application for assistance to the medically indigent and fails to report the following may be personally liable for any money incorrectly paid to the recipient:
1)any required information to the Division of Welfare and Supportive Services which the individual knew at the time they signed the application; or
2)within the period allowed by the Division of Welfare and Supportive Services, any required information to the Division of Welfare and Supportive Services which the individual obtained after filing the application.
I understand, that as a parent of a disabled minor child who receives services under the Medicaid program:
1)I am responsible to contribute to the support of my child by reimbursing the State of Nevada, Division of Welfare and Supportive Services for said services pursuant to NRS 125B.020; and NRS 422.310.
2)I agree to cooperate with the Division of Welfare and Supportive Services and provide to the Division of Welfare and Supportive Services, Medicaid program, all information regarding income, resource and medical insurance, necessary to determine the amount of the reimbursement.
3)I understand if I fail to cooperate or fail to provide the requested information, I will be responsible for a monthly reimbursement payment in the amount of $1,900.
I understand the “period of intended use” for SNAP benefits deposited into an EBT account is 365 days from the date they became available. SNAP benefits left untouched in an EBT account for 365 days will be removed from the account and returned to Food and Nutrition Services (FNS) as required by federal regulations. Federal regulations do allow unused benefits to be applied (credited) to any outstanding SNAP claim (debt) the household may have incurred prior to being returned to FNS. I hereby give the Division of Welfare and Supportive Services permission to apply any unused EBT SNAP benefits to any unpaid or outstanding SNAP debt I or any other adult member of my household owes to the SNAP Program.
(CONTINUED ON NEXT PAGE)
6
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 such information from liability, if any, resulting from the disclosure of the required information.
I understand the questions on this application and the penalty for hiding or giving false information. I agree to notify the Division of Welfare and Supportive Services of any changes in my circumstances that may affect my eligibility for assistance. I understand failure to report changes in circumstances may result in overpayment collection/criminal prosecution.
I understand Social Security Numbers (SSNs) are used to verify income and resources, to see what benefits are available, as case numbers in the computer, gather workforce information for research which helps lawmakers and agencies improve services to Nevadans, investigate fraud, recover overpaid benefits, make sure nobody gets benefits in more than one household (double benefits) or while they are in jail or prison or deceased and match against other federal and state records. For example: Child Support Enforcement Program (CSEP), Unemployment Insurance Benefits (UIB), Internal Revenue Service (IRS), Medicaid and Social Security Administration (SSA), law enforcement/prison records. By signing this application, I allow the agency to use my SSN for the purposes explained on this form. This includes anyone under age 18 I am applying for.
I hereby authorize the Nevada Department of Health and Human Services to make any investigation concerning me or other members of my household which is necessary to determine eligibility for any benefits I have received or will receive under programs administered by the Division of Welfare and Supportive Services. I hereby authorize and consent to the release of all information concerning me and/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. This information may also include education records (including IEP records) maintained at the local school district that are necessary for Medicaid reimbursement purposes for health services provided to my child. I hereby release the holder of the information from liability, if any, resulting from the release (disclosure) of the required information. A REPRODUCED COPY OF THIS
AUTHORIZATION LEGALLY CONSTITUTES AN ORIGINAL COPY.
I realize that I must give complete and accurate information and that willful concealment of income and assets could result in criminal prosecution. I certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability.
If you are applying for someone else and they are unable to sign, sign your name for them on the applicant's signature line (e.g., John Doe for Mary Doe).
____________________________________________________________________________________________________
Signature or Mark of Applicant
Signature or Mark of Applicant's SPOUSE
WITNESS: (USE IF APPLICANT CANNOT READ OR WRITE OR IS BLIND)
The Information Contained In This Application Has Been Read To The Applicant And I Have Witnessed The Above Signature
Signature Of Witness
IN CASE OF EMERGENCY, NOTIFY:
Relationship
Telephone #
The person applying for assistance MUST SIGN below.
Citizen
Non-citizen
I certify under penalty of perjury, by signing my name below, that I have
or
Lawfully
reported the correct citizenship status for all household members.
National
Admitted
1.
2.
FOR OFFICE USE ONLY
Case Manager Signature
7
RECIPIENT'S RIGHTS AND OBLIGATIONS
AS AN APPLICANT/RECIPIENT FOR WELFARE BENEFITS FROM THE STATE OF NEVADA, YOU ARE HEREBY ADVISED THAT:
You have the following RIGHTS:
1.You have the right to a hearing if your application for assistance or services is denied, reduced, terminated, or not acted on with reasonable promptness unless state or federal law requires such action. You may obtain a hearing by mailing in a written request to the Division of Welfare and Supportive Services. You may be represented by legal counsel or by a relative, friend or other spokesperson, or you may represent yourself.
2.The Division of Welfare and Supportive Services provides medical assistance and services without discrimination of any kind (such as race, age, color, religion, sex, disability, handicap [including AIDS and AIDS-related conditions], political belief or national origin) according to federal rules and regulations. When the Division pays another agency, institution or person for services to clients of the Division of Welfare and Supportive Services, the vendor is not permitted to discriminate for any reason (such as race, age, color, religion, sex, disability, handicap [including AIDS and AIDS-related conditions], political belief or national origin) according to federal rules and regulations.
Violations of this provision should be promptly reported to the nearest district office, the Division of Welfare and Supportive Services Administrator, 1470 College Parkway, Carson City, Nevada 89706-7924, (775) 684-0500, the U.S. Office for Civil Rights (OCR), Department of Health and Human Services, 50 United Nations Plaza, San Francisco, California 94102, (415) 437-8310, TDD (415) 437-8311 or toll free 1-800-368-1019 or the Secretary of Agriculture, Washington, D.C. 20250.
3.If you are married and living separate and apart from your spouse, you have the right to enter into a written agreement which equally splits your community income and/or resources between you. If this is done, only the income or resources the agreement specifies as yours will be counted in determining eligibility, unless your spouse makes a portion of his/her income or resources available to you. The portion made available to you will be counted when determining/continuing your eligibility. The written agreement must be specific as to what assets are being divided and how they will be divided between you. It is suggested you consult legal assistance if you decide to enter into such an agreement.
4.When there is a court order dividing community resources, excluding income, between you and your spouse under provisions of 1987 Statutes of Nevada Chapter 123, only these resources awarded to you will be counted in determining/continuing your eligibility unless your spouse makes a portion of his/her resources available to you. The portion made available to you will be counted in determining/continuing your eligibility.
You have the following OBLIGATIONS:
1.Institutionalized persons or persons receiving nursing care at home (includes SSI and non-SSI recipients) may be responsible for paying a portion of their income toward the cost of their care. This is called patient liability. The division district office must be notified immediately of any income changes.
2.All household members must provide proof of their Social Security Number, or their application to obtain a number. The Division of Welfare and Supportive Services’ authority to require Social Security Numbers is Section 1137 of the Social Security Act. The Social Security Number is used to determine and verify eligibility for benefits through such means as computer matching and to prevent and detect fraud and abuse.
3.If you are applying for/receiving Supplemental Security Income (SSI), you must inform your Case Manager immediately of the following:
a.Written proof of your application for SSI (Supplemental Security Income);
b.Proof of your SSI eligibility determination;
c.Termination of SSI;
d.ANY CHANGES IN ADDRESS;
e.Income (if you are institutionalized);
f.Any other changes/information that may affect your eligibility for assistance.
4.If you are NOT receiving Supplemental Security Income (SSI), you must inform your caseworker immediately of the following:
8
Completing the Nevada Division Welfare form is an important step in applying for assistance programs. Follow these steps carefully to ensure that your application is filled out correctly. Make sure to provide accurate information, as it will be verified by the Division of Welfare and Supportive Services.
Once you have filled out the form, make sure to keep a copy for your records. Submit the application to the appropriate office to initiate the assistance process. If you need further assistance, do not hesitate to reach out to the Division of Welfare and Supportive Services.
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1. What is the Nevada Division Welfare form used for?
The Nevada Division Welfare form is an application for various public assistance programs, including Medicaid and the Supplemental Nutrition Assistance Program (SNAP). It helps low-income individuals and families access medical assistance and food benefits. By filling out this form, applicants can receive support for healthcare costs and help with purchasing food.
2. Who is eligible to apply for Medicaid through this form?
Eligibility for Medicaid includes individuals who are over 65, blind, or disabled. Additionally, non-citizens who meet specific program requirements and qualified Medicare beneficiaries can apply. The form is designed to gather information necessary to determine if applicants meet these criteria.
3. How do I know if I qualify for SNAP benefits?
To qualify for SNAP benefits, your household's gross monthly income must be low enough to meet the program's requirements. If your monthly rent or mortgage, along with utilities, exceeds your household's income, or if your gross monthly income is less than $150 with resources of $100 or less, you may qualify for immediate SNAP assistance.
4. What should I do if I need help completing the form?
If you find the application process challenging, consider asking a family member, friend, or a case manager from the Division of Welfare and Supportive Services for assistance. They can guide you through each section and ensure you provide the necessary information accurately.
5. What happens if I do not provide a Social Security Number (SSN)?
Providing an SSN is essential for individuals seeking assistance. If you or someone in your household does not wish to provide an SSN, that person’s request for assistance will be denied. However, their income and resources may still be counted towards other household members applying for benefits.
6. Is proof of citizenship or immigration status required?
Yes, proof of citizenship or immigration status is required when applying for Medicaid or SNAP. However, if you or a family member do not wish to apply for SNAP benefits, you do not need to provide this information. If you want to determine eligibility for other family members, you still need to disclose their citizenship or immigration status.
7. What should I do if I am applying on behalf of someone else?
If you are completing the form for someone else, make sure to check the appropriate boxes and fill in the necessary spaces as they apply to that individual. This ensures that the application accurately reflects the information needed for the person you are assisting.
8. How long does it take to process the SNAP application?
The Division of Welfare and Supportive Services must take action on your SNAP application within 30 days of submission. If you qualify for expedited benefits, this action must occur within 7 days. Benefits will be provided from the date you submit the first page of the application.
9. What should I do if I suspect discrimination during the application process?
If you believe you have experienced discrimination based on race, color, national origin, sex, age, or disability while applying for assistance, you can file a complaint. Contact the USDA or HHS Office for Civil Rights to report your concerns. They provide resources to ensure that all applicants receive fair treatment.
Neglecting to Read Instructions Carefully: Many applicants skim through the instructions or skip them entirely. This can lead to incomplete or incorrect information being provided.
Failing to Answer All Questions: It’s essential to respond to every question. If a question does not apply, write “NONE” instead of leaving it blank.
Incorrectly Reporting Income and Assets: Some applicants may underestimate or misreport their income and assets. Remember, accuracy is crucial, as discrepancies can lead to serious consequences.
Not Providing Required Documentation: Applicants often forget to include necessary documentation, such as proof of income or citizenship. Ensure you gather all required documents before submission.
Ignoring Deadlines: Missing deadlines can delay the processing of your application. Be aware of the timelines for SNAP benefits and other assistance programs.
Overlooking Signature Requirement: Some applicants forget to sign the application. Without a signature, the form is considered incomplete.
Not Seeking Help When Needed: Many individuals hesitate to ask for assistance when filling out the form. If you’re unsure about any part, reach out to a family member, friend, or case manager.
Misunderstanding the Importance of Social Security Numbers: Applicants may not realize the necessity of providing Social Security Numbers for all household members. Omitting this information can result in denial of assistance.
When applying for assistance through the Nevada Division of Welfare, several other forms and documents may be required to support your application. Each of these documents serves a specific purpose in the evaluation of your eligibility for assistance programs such as Medicaid and SNAP. Below is a list of commonly used forms and documents that you might encounter during this process.
Gathering these documents ahead of time can streamline the application process and help ensure that you provide all necessary information for your eligibility assessment. Each document plays a crucial role in determining the level of assistance you may receive, so it's important to pay attention to the specific requirements outlined by the Nevada Division of Welfare.