Download Nevada Welfare Division Template Open Editor Now

Download Nevada Welfare Division Template

The Nevada Welfare Division form is an application for assistance provided by the Division of Welfare and Supportive Services. This form allows individuals and families to apply for essential programs such as Food Assistance through the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). Completing this form is a crucial step for those seeking financial support in Nevada, so consider filling it out by clicking the button below.

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Nevada Welfare Division Example

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 households 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.govOnline: 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.

2905 EG (8-17)

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 discrimination 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.

 

 

MiddleInitial

ModifierJr. Sr.

Last Name

First Name

 

Relation to

 

 

 

You

SELF

Are there additional people in your home? YES

Gender

Date of

Age

Marital Status**

Social

State or

CitizenU.S.

Y/N

*Race/Ethnicity

GradeLast Completed

Month/Year Completed

FOOD

TANF

NONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Security

Country

 

 

 

 

 

 

 

 

 

Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

Number

of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 others you live with?

If “NO”, list who buys their food separately

YES

NO

2.

List the total gross amount of money your household received or expects to receive this month.

$_______________

3.

How much do all persons have in cash, checking 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 household 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 ONLYEXPEDITED SERVICE SCREENING: HOUSEHOLD ELIGIBLE FOR EXPEDITED SERVICE?

YES NO Expedited service screener signature: ________________________________________

DATE: __________________

4

FOOD & TANF

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 you 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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOOD & TANF

 

 

 

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

NO

 

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

NO

 

8. In case of emergency, who would you like us to contact? Name

 

 

Relationship

 

 

 

 

 

Daytime Telephone # ( )

-

Address

 

 

 

 

 

 

 

 

 

FOOD & TANF

 

 

 

ADDITIONAL HOUSEHOLD INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Do you plan to continue living in Nevada? If “NO”, explain:

YES

NO

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

NO

 

If “YES,” who?

 

 

What tribe?

 

 

 

12.

Are you or any person(s) in your household currently disqualified for an Intentional Program

 

 

 

Violation (IPV)?

 

 

 

 

YES

NO

 

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?

If “YES”, who?

 

 

 

 

 

 

 

 

 

 

 

YES

NO

When?

 

 

 

 

Where?

 

 

 

 

b. Have you or any person(s) in your household been convicted of trading SNAP benefits 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 benefits 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 benefits 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, being 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?

___________________________________________

 

 

 

 

5

 

 

FOOD & TANF

 

 

 

 

 

 

PREGNANCY

 

 

 

 

 

 

 

PREG

 

 

16. Are you or any person(s) in your household pregnant?

 

 

 

 

 

 

 

YES

NO

 

 

If “YES”, who?

 

 

Expected due date?

/

/

 

(MM/DD/YYYY)

 

FOOD & TANF

 

 

 

 

 

 

DISABILITY

 

 

 

 

 

 

 

DISA

 

 

17. Are you or any person(s) in your household blind, disabled or unable to work due to illness or injury?

 

 

YES

NO

 

 

If “YES”, who?

 

 

 

When did this condition begin?

 

/

 

/

 

(MM/DD/YYYY)

 

 

What is the disability?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOOD & TANF

 

 

 

 

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? ___________________

 

FOOD & TANF

 

 

 

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

 

 

6

22.

Are you or any person(s) in your household currently registered with or working for a temporary employment

 

 

 

 

service/agency?

 

 

 

 

 

 

 

 

 

YES

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?

 

 

 

 

 

 

FOOD & TANF

 

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) ____________________________

 

$

7

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:

 

YES

TYPE OF ACCOUNT

Savings Account

Checking Account

Credit Union Account

Minor Savings

Business Account

Christmas Club

Account

Educational Savings Account

Patient Trust Fund

Individual Indian Money Account

BANK ACCOUNTS

 

 

 

ACCOUNT

 

 

 

NUMBER

OWNER(S)

NAME OF BANK

VALUE

(Please list the

 

 

 

last 4 numbers

 

 

 

only)

$

$

$

$

$

$

$

$

$

LIFE INSURANCE/TRUSTS/BURIALS

YES

TYPE OF ACCOUNT

Life Insurance

Available Trusts

Unavailable Trusts

Burial Funds/Plans

Life Estates

 

 

 

 

 

 

 

POLICY OR

 

 

 

NAME OF COMPANY

 

 

 

 

ACCOUNT

 

OWNER(S)

 

 

FACE VALUE

 

 

NUMBER

 

 

OR BANK

 

 

 

 

 

 

 

 

 

 

(Please list the last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 numbers only)

 

 

 

 

$

/CSV$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

/CSV$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOOD & TANF

RESOURCES (CONT)

BANK/LIFE/PROP

YES

INVESTMENT & RETIREMENT ACCOUNTS

 

 

 

 

ACCOUNT

TYPE OF ACCOUNT

OWNER(S)

NAME OF BANK OR

VALUE

NUMBER

(Please list the

COMPANY

 

 

 

last 4 numbers

 

 

 

 

 

 

 

 

only)

Savings Bonds

Stocks or Bonds

Certificates of Deposit

Individual Retirement

Accounts (IRA)

Keogh Account (401K)

Annuities

8

PERSONAL PROPERTY

 

 

 

 

 

 

CURRENT

 

YES

TYPE OF PROPERTY

OWNER(S)

LOCATION

CONTENTS OR TYPE OF

OR

 

RESOURCE

MARKET

 

 

 

 

 

 

 

 

 

 

VALUE

 

 

Safe Deposit Box

 

 

 

$

 

 

Livestock

 

 

 

$

 

 

Land Mineral Rights

 

 

 

$

 

 

Mining Claims

 

 

 

$

 

 

Business Equipment/

 

 

 

$

 

 

Inventory

 

 

 

 

 

 

Houses/Land or

 

 

Is this property currently

$

 

 

Buildings

 

 

for sale? Yes No

 

 

 

 

 

 

 

 

MISCELLANEOUS

YES

TYPE OF RESOURCE

OWNER(S)

 

Promissory Notes

Cash on Hand

Other: (please list)

28. Are any of the resources in question 27 designated as money for burial?

If “YES”, which resources?

CURRENT VALUE

$

$

$

YES NO

 

FOOD & TANF

 

 

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.

OWNER

TYPE OF

YEAR, MAKE &

IS THE VEHICLE

FAIR MARKET

AMOUNT

VEHICLE

MODEL

REGISTERED

VALUE

OWED

 

 

 

 

 

 

 

 

 

 

 

YES

NO

$

$

 

 

 

YES

NO

$

$

 

 

 

YES

NO

$

$

FOOD

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?

 

 

 

 

 

 

 

 

FOOD

 

 

 

 

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?

_________________________

Landlord’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?

 

 

 

 

 

 

 

9

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 expense include costs for heating or cooling?

 

 

 

 

 

 

YES

 

NO

 

 

If “NO”, please choose the utilities your household is responsible for paying:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Electricity

 

Wood

 

 

Water

 

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”, who?

Telephone?

 

How much? $

 

 

How often?

 

 

 

 

b. Does your household receive or expect to receive assistance from the Energy Assistance Program?

 

 

 

YES

 

NO

 

FOOD & TANF

 

 

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 insurance?

 

 

 

 

 

 

 

 

 

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? $

 

 

 

 

 

 

 

 

 

 

 

TANF

 

 

 

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 receive an insurance reimbursement, payment or

 

 

 

 

 

 

 

legal settlement?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

If “YES”, who?

when?

 

 

How much $

From where?

 

 

 

 

 

 

 

 

 

 

TANF

 

 

 

 

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 pregnant, is the father of the unborn in the home?

 

 

 

 

 

 

YES

 

NO

 

 

If “YES”, who is the father?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Guide to Writing Nevada Welfare Division

After completing the Nevada Welfare Division form, you will submit it to the appropriate office for processing. Eligibility determinations will be made based on the information provided, and you will receive further instructions or notifications regarding your application status.

  1. Obtain the Nevada Welfare Division form, ensuring you have the latest version.
  2. Fill out your personal information at the top of the form, including your name, address, and contact details.
  3. List all individuals living in your household, including their relationship to you and any unborn children.
  4. Indicate your household's income by answering questions related to your gross monthly income and resources.
  5. Provide information about your housing costs, including rent or mortgage and utilities.
  6. Answer questions regarding your employment status and any previous assistance received from TANF or SNAP.
  7. Complete the citizenship and immigration status section for all household members.
  8. If applicable, designate an authorized representative to act on your behalf.
  9. Sign and date the application to certify that the information is accurate.
  10. Review the completed form for accuracy and completeness before submission.
  11. Mail or submit the signed application to the address provided on the form.

More PDF Documents

Understanding Nevada Welfare Division

What programs can I apply for using the Nevada Welfare Division form?

You can apply for two main programs using the Nevada Welfare Division form: the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). SNAP helps individuals and families buy food, while TANF provides cash assistance to families with children to meet their basic needs.

How long does it take to process my application?

The processing time varies by program. SNAP benefits are typically processed within 30 days from the application date. However, if your household has little or no income, you might receive benefits within 7 days. For TANF, applications are usually processed within 45 days, but benefits are paid from the date of approval or 30 days from the application date, whichever comes first.

What should I do if I need help with my application?

If you need assistance with your application, you can reach out through various channels. You can call the toll-free number 1-800-992-0900 ext 47200, or contact local offices in Southern Nevada at (702) 486-1646 or Northern Nevada at (775) 684-7200. Email support is also available at welfare@dwss.nv.gov. For in-person help, visit a local DWSS District office or check the website for more information.

Do I need to provide my Social Security Number (SSN) when applying?

What information about citizenship or immigration status is required?

You must provide information regarding the citizenship or immigration status of everyone applying for assistance. If any applicant refuses to provide this information, they will not be eligible for SNAP benefits. For TANF, the refusal of a required household member to provide verification will make the entire household ineligible.

Where should I send my completed application?

Once you have completed and signed your application, mail it to the following address: State of Nevada Division of Welfare and Supportive Services, P.O. Box 15400, Las Vegas, NV 89114-5400. After submission, you will be notified about your eligibility or given further instructions.

Common mistakes

  1. Failing to provide complete information for all household members. All individuals living in the home should be listed, regardless of their status.

  2. Not including Social Security Numbers (SSNs) for all applicants. Omitting this information can lead to ineligibility for benefits.

  3. Neglecting to verify citizenship or immigration status. This is a requirement for all applicants and affects eligibility.

  4. Inaccurately reporting income. Providing incorrect figures can lead to delays or denials of assistance.

  5. Missing deadlines for submitting required documentation. Timely submission is essential for processing applications.

  6. Not providing proof of residency in Nevada. This can include documents like a lease agreement or utility bills.

  7. Ignoring the need for identification. Applicants must bring proper identification to their interviews.

  8. Failing to disclose previous benefits received. This includes benefits from other states and can impact eligibility.

  9. Not seeking help when needed. Applicants can reach out for assistance but may hesitate to do so.

  10. Providing incomplete or unclear answers on the application. This can lead to confusion and delays in processing.

Document Data

Fact Name Description
Programs Available The Nevada Welfare Division form allows applications for two main programs: Food Assistance (SNAP) and Temporary Assistance for Needy Families (TANF).
Processing Time SNAP benefits are typically processed within 30 days, with expedited services available for eligible households, allowing benefits to be received within 7 days.
Social Security Number Requirement Applicants must provide Social Security Numbers for all household members to verify income and resources, as mandated by Title 42 USC 1320b-7 and the Food and Nutrition Act of 2008.
Citizenship Verification All applicants must provide information regarding their citizenship or immigration status. Failure to do so may result in ineligibility for TANF benefits.
Non-Discrimination Policy The Nevada Welfare Division prohibits discrimination based on race, color, national origin, disability, age, sex, and other factors, ensuring equal opportunity in assistance programs.

Documents used along the form

When applying for assistance through the Nevada Welfare Division, several other documents may be necessary to support your application. These documents help verify your identity, income, and residency, ensuring that you meet the eligibility requirements for the programs you are applying for. Below is a list of commonly used forms and documents that accompany the Nevada Welfare Division form.

  • Identification Documents: These include items like a U.S. passport, driver's license, or military ID. They confirm your identity and citizenship status, which are essential for eligibility.
  • Last Will and Testament Form: To secure your legacy, consider utilizing our comprehensive Last Will and Testament resources to guide you through the documentation process.
  • Income Verification: This may consist of pay stubs, tax returns, or award letters for benefits like Social Security. This documentation helps to establish your financial situation and determine your eligibility for assistance.
  • Residency Proof: Documents such as a current lease agreement or utility bills can demonstrate that you reside in Nevada. This is a requirement for receiving state benefits.
  • Verification of Benefits: If you receive assistance from another state, you may need to provide proof of those benefits. This helps to clarify your current financial situation and avoid duplicate benefits.
  • Expense Documentation: You may need to submit receipts or statements for expenses like rent, utilities, or child care. These documents provide a clearer picture of your financial obligations and needs.

Gathering these documents ahead of time can streamline the application process and help ensure that you receive the assistance you need as quickly as possible. Always check with the Nevada Welfare Division for any specific requirements or additional documents that may be necessary for your situation.

Similar forms

The Nevada Welfare Division form is similar to several other documents related to assistance programs. Each of these documents serves a specific purpose and shares common elements, such as the need for personal information and eligibility verification. Below is a list of nine documents that are comparable to the Nevada Welfare Division form:

  • Supplemental Nutrition Assistance Program (SNAP) Application: Like the Nevada Welfare Division form, this application requires personal information and details about household income to determine eligibility for food assistance.
  • Temporary Assistance for Needy Families (TANF) Application: This document also requests information about household members and income to assess eligibility for cash assistance, similar to the TANF section in the Nevada form.
  • Dog Bill of Sale: This form is essential for documenting the sale and transfer of ownership of a dog in California. It captures important details such as the dog's description and the sale price. For assistance with completing this form, visit legalpdf.org.
  • Medicaid Application: This form collects personal and financial information to evaluate eligibility for healthcare assistance, paralleling the need for income verification in the Nevada Welfare Division form.
  • Women, Infants, and Children (WIC) Program Application: This application requires details about family size and income to qualify for nutritional support, akin to the information requested in the Nevada Welfare Division form.
  • Public Housing Application: Like the Nevada form, this document gathers information about income and family composition to determine eligibility for housing assistance.
  • Low-Income Home Energy Assistance Program (LIHEAP) Application: This form seeks information about household income and expenses to assess eligibility for energy assistance, similar to the financial information required by the Nevada Welfare Division.
  • Child Care Assistance Application: This application collects details about income and household size to determine eligibility for child care support, mirroring the structure of the Nevada form.
  • Unemployment Benefits Application: Like the Nevada Welfare Division form, this document requires personal information and income history to evaluate eligibility for unemployment assistance.
  • Social Security Disability Insurance (SSDI) Application: This application requires detailed personal and medical information to assess eligibility for disability benefits, similar to the verification processes outlined in the Nevada Welfare Division form.