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Fill Out a Valid Nevada Division Welfare Template

The Nevada Division Welfare form serves as a crucial application for individuals seeking assistance through various public assistance programs in Nevada, including Medicaid - Medical Assistance to the Aged, Blind, and Disabled (MAABD), and the Supplemental Nutrition Assistance Program (SNAP). This form is designed to ease the process for low-income households and individuals who meet specific eligibility requirements, offering a pathway to gain access to medical assistance, food assistance, and other vital services. It emphasizes the need for accurate and honest completion to avoid any potential legal issues, including criminal prosecution for willful concealment of information.

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Fill Out a Valid Nevada Division Welfare Template

Outline

In the bustling state of Nevada, residents seeking assistance for medical needs, food supplementation, and support for the aged, blind, and disabled navigate through the application process with the Nevada Division Welfare Form. This comprehensive document, meticulously crafted by the State of Nevada Department of Health and Human Services, Division of Welfare and Supportive Services, serves as a gateway to various public assistance programs including Medicaid and the Supplemental Nutrition Assistance Program (SNAP). Applicants are guided through each section, ensuring they have the required information about medical assistance options for those over age 65, blind, or disabled, as well as food assistance for low-income households. The form underscores the importance of accurate completion, offering assistance in filling it out and emphasizing the serious implications of willfully concealing income or assets. With clear instructions for applicants acting on behalf of another, a thorough verification process, and a non-discrimination policy, the form aims to streamline the application process. It also highlights the rights and obligations of recipients, processes for applying for SNAP benefits promptly, and the crucial requirement for Social Security Numbers to facilitate eligibility verification and benefit coordination among federal and state agencies. The document thoughtfully addresses contingencies for non-applicants or those unable to provide an SSN due to various reasons, ensuring a fair and inclusive approach to assistance.

Sample - Nevada Division Welfare Form

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

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

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.

Division of Welfare and Supportive Services

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	NUMBER	COUNTRY
LAST NAME, FIRST	RELATION	E	(optional see	OF
	TO YOU	X	cover page)	BIRTH

self

CITIZEN?	Y/N
U.S.

*RACE/ETHNICITY

DATE

BIRTH

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		City		State	Zip

Mailing Address		City		State	Zip

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

3.Has anyone, applying for assistance, RECEIVED any type of public assistance in the

past 90 days?							YES	NO
If YES, Who:		Where:				When:
	Name of Person		City	County	State			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

YES

Who:

5.Has anyone, applying for assistance, been in a hospital, nursing home or other medical


	institution during the past 3 months?				YES	NO
	Are you currently in a hospital, nursing home, or other medical facility?				YES	NO
	If YES, Who:	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.

8.Is any household member a veteran?


Name	Branch of		VA Claim Number	Serial Number	Dates of Service
Name	Service		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?					YES		NO
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 #

YES

11.

Does anyone have any health/dental insurance or is it available to you from any source?

YES

Who:

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?

YES

Who:

When:

13.

Do you want someone other than yourself to apply for benefits or act on your behalf?

YES

(This would include obtaining and using SNAP for you. This person must be at

least 18 and have I.D.) If YES, complete below.

Who:

Name

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?

YES

15.

Is this residence occupied by a community spouse, dependent relative or other person?

YES

16.

Do you receive rental income from your home?

YES

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

PROP

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

Owner(s)

Resource

Type

Account/Policy

Number

Amount

Value

Amount

Owed

20. Are any of the resources, in question 19, MONEY FOR BURIAL?					YES	NO
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	None
Truck/Van	Snowmobile	Boats/Motors	Other Vehicle (dune buggy, ATV, etc.) _____________________

Owner(s)

Year, Make &

Model

Check if Value Registered

Owner(s)

Year, Make

& Model

Check if Value Registered


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?			YES	NO
	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?			YES	NO

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:	—	—

Name:

Start:	—	—

End:	—	—

Name:

Start:	—	—

End:	—	—

Name:

Start:	—	—

End:	—	—

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?		YES	NO
If YES, complete boxes below.
Child Support/Alimony (Absent Parent)	Mining Claims	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

Amount

How Often

Income Type

Who Receives

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

Address

Social Security Number

Date of birth

Date of death

Veteran?

YES

Divorced?

YES

Widowed?

YES

Claim #

Date:

Employer name/address

Medical insurance

Are you covered?

YES

Railroad, federal or local government employee?

YES

RR or gov’t claim number

Years employed

Spouse’s Name

Address

Social Security Number

Date of birth

Date of death

Veteran?

YES

Divorced?

YES

Widowed?

YES

Claim #

Date:

Employer name/address

Medical insurance

Are you covered?

YES

Railroad, federal or local government employee?

YES

RR or gov’t claim number

Years employed

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?					YES	NO
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?					YES	NO
	When?	–	–	City/County/State?

32. Is any household member on strike? If YES, complete below.					YES	NO

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?

YES

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?

YES

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?	YES	NO Amount $__________
39. Does anyone in the household expect any changes in income, expenses or work hours?		YES	NO

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?						YES	NO
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	$	Other	$

42.	Does anyone else pay a portion of your rent or utilities?		YES	NO
	Who?	How much?
43.	Is the rent government subsidized (HUD, Section 8, Federal Public Housing, etc.)?		YES	NO

44.List landlord’s/rental company’s name, address and phone number.

Landlord’s Name

Address

Telephone

FOR OFFICE USE ONLY - EXPEDITED SERVICE SCREEN - Household eligible for expedited service.

YES

NO Expedited Service Screener’s Signature:

Date:

SIGNATURE AND AFFIRMATION

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)

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

Date

Signature or Mark of Applicant's SPOUSE

Date

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		Address						Date
IN CASE OF EMERGENCY, NOTIFY:

	Name	Relationship		Address			Telephone #
The person applying for assistance MUST SIGN below.
			U.S.
			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	Other		Date

1.

2.



		FOR OFFICE USE ONLY

	Case Manager Signature						Date
		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:

⇩ Nevada Division Welfare File

Form Specs

Fact	Detail
Governing Law for Social Security Number Disclosure	Title 42 USC 1320b-7 requires Social Security Numbers (SSN) for individuals receiving or applying for assistance.
Application Components	Includes applications for Medicaid, SNAP, and information on rights and obligations of recipients.
Verification and Application Processing	The Division of Welfare and Supportive Services verifies provided information and processes SNAP applications within 30 days, and expedited processing within 7 days under certain conditions.
Non-Discrimination Policy	Adheres to Federal law and USDA and HHS policies, prohibiting discrimination based on race, color, national origin, sex, age, disability, religion, or political beliefs.

How to Fill Out Nevada Division Welfare

Filling out the Nevada Division of Welfare and Supportive Services form is a necessary step for individuals and families in Nevada seeking assistance with Medicaid, SNAP, or other public assistance programs. This process might seem daunting at first, but with a little guidance, it can be tackled with confidence. Taking the time to accurately complete the application ensures that the Division can effectively assess eligibility for the benefits needed. Let's dive into the step-by-step instructions to make sure every section of the application is filled out correctly.

Read the entire application carefully. Make sure to understand each section before you start writing. If a question does not apply to you, write "NONE" as your answer.
If you are unsure about any part of the application or need assistance, consider asking a family member, friend, or a case manager from the Division of Welfare and Supportive Services.
Begin by certifying that you will provide accurate and truthful answers on the application. Remember, the information provided will be verified, and willful concealment can lead to legal repercussions.
Check the appropriate boxes or fill in the blanks as applicable to the person for whom the application is being made, especially if you are not applying for yourself.
For SNAP applications, remember the verification process for information provided must be completed within 30 days, and eligibility for benefits counts from the date the first page of the application was submitted. Immediate needs for SNAP may prompt action within 7 days.
Disclose all required Social Security Numbers for individuals receiving or seeking to receive assistance. Remember, failing to provide an SSN or not applying for one could result in a denial of assistance for that individual.
Complete the section regarding citizenship and/or immigration status, as it's necessary for determining eligibility for TANF-cash assistance, Medicaid, or SNAP.
Adhere to non-discrimination policies by understanding that assistance programs are available to all eligible individuals without regard to race, color, national origin, sex, age, or disability.
For children not eligible for Medicaid, consider the Nevada Check Up Program for low-cost health care coverage, and ensure to gather more information if applicable.
Fill out the specific applicant information section, making sure to include details about each household member's race (optional), marital status, social security number or alien registration number, relationship to you, and other required information.
Answer the residence and resource information questions, listing all household resources, vehicles, and their values accurately.
Detail any transactions involving sale, trade, or gifts of money, vehicles, property, or other resources in the last 60 months.
Complete the income information section with current and last employment details for all household members, including employer name, address, employment periods, wages, and reasons for leaving.
Sign and date the application, ensuring to photocopy and date stamp page 1 to establish the application date.

Once the application is completed and signed, it is ready to be submitted to the nearest Division of Welfare and Supportive Services office. Providing thorough and accurate information will expedite the review process and bring you closer to receiving the assistance needed. The meticulous filling of each part ensures that you meet the application requirements and can aid in securing the essential benefits for you or your family member.

Obtain Clarifications on Nevada Division Welfare

What types of assistance can I apply for using the Nevada Division Welfare form?

You can apply for Medicaid, specifically the Medical Assistance to the Aged, Blind, and Disabled (MAABD), and the Supplemental Nutrition Assistance Program (SNAP). Medicaid provides medical assistance for low-income individuals who are over 65, blind, disabled, certain non-citizens, and those qualifying for Medicare beneficiaries. SNAP offers food assistance to low-income households to help supplement their food purchases.
How do I complete the application if I need assistance?

If you need help completing the application, you are encouraged to ask family, a friend, or a case manager from the Division of Welfare and Supportive Services (DWSS). It is important to read each question carefully and provide complete and accurate information to the best of your ability.
What happens if I provide incorrect information on my application?

Providing false information or willfully concealing income and assets may result in criminal prosecution. The Division of Welfare and Supportive Services verifies the answers provided on the form. It is crucial to answer honestly and accurately.
What should I do if I am applying on behalf of someone else?

If you are filling out the form for another person, you should check the boxes and complete blank spaces as they apply to the individual for whom you are applying. Ensure to provide accurate information for that individual’s circumstances.
When can I expect action to be taken on my SNAP application?

Your SNAP application will be processed within 30 days from the date of submission. However, if you meet certain criteria such as having monthly rent/mortgage and utilities surpassing your household's gross monthly income, or having a gross monthly income less than $150 with $100 or less in household resources, your application may be expedited, and action must be taken within 7 days.
Is providing a Social Security Number (SSN) mandatory?

Yes, providing SSNs for all individuals receiving or seeking to receive assistance is required by federal law, unless the individual is undocumented, a non-qualified non-citizen, or considered a non-applicant for other reasons. SSNs are used for verification of income, resources, and for administrative purposes such as ensuring duplicate benefits are not issued.
Why do I need to disclose my citizenship or immigration status?

Proof of citizenship or immigration status is required to determine eligibility for TANF, Medicaid, or SNAP. If certain family members do not have eligible immigration status, they may be ineligible for benefits, but it does not necessarily affect the eligibility of other members in your household who may qualify.
What is Nevada Check Up Program?

Nevada Check Up Program is designed to provide low-cost, comprehensive health care coverage to uninsured children aged 0-18 who are not covered by private insurance or Medicaid. You can learn more about the eligibility requirements or request an application by visiting their website or calling the provided number.
What information do I need to disclose about my vehicle and other assets?

You must list all vehicles (including those that do not run), bank accounts, property, and any other assets for all household members applying for assistance. If any assets were sold, traded, or given away, or if you or your spouse have been involved with a trust, annuity, or life estate, detailed information about these transactions and assets must be disclosed on the application.

Common mistakes

Filling out forms for any state department can feel daunting, including the Nevada Division Welfare form. This document is key in accessing vital services like MEDICAID and SNAP. Despite its importance, mistakes can happen. Here’s a look at five common errors to avoid.

Firstly, a significant error involves not answering every question. It might seem inconsequential to leave a field blank, especially if you think it doesn’t apply to you. However, instructions clearly state to fill in every question; if the answer is “none,” you should explicitly write “NONE.” This simple step prevents any assumptions on the reviewer's part about whether you forgot to answer or if the question truly doesn’t apply to you.

Overlooking the need for assistance during the application process is another mistake. The form encourages applicants to seek help if they have trouble filling it out. Instead of struggling alone or making incorrect entries, reaching out to family, friends, or a case manager can significantly ease the process.
Many applicants aren’t aware that the information they provide will be verified. It’s crucial to be honest and thorough in your responses. Willful concealment of any details, especially about income and assets, can have serious consequences, including criminal prosecution.
A common oversight involves applicants forgetting to fill out sections that also apply to other household members if they are applying on someone else’s behalf. It’s important to remember that each checkbox or blank space must be completed accurately, reflecting the situation of the person the application is intended for.
Not considering the verification timeline for SNAP benefits is another frequently seen mistake. Applicants must understand that the information they provide for SNAP purposes will be verified within a certain period. If eligible, benefits are provided from the date of the first submitted page. Knowing this can influence when you decide to submit your application, especially if you qualify for expedited processing.

Details matter in applications like these. Every question is an opportunity to ensure you’re fully considered for the assistance you need. An overlooked mistake can delay or even impact your eligibility. Give each question your full attention, and remember, help is available if you need it. Accuracy, honesty, and completeness are your best allies in navigating the application process efficiently.

Documents used along the form

Applying for assistance through the Nevada Division of Welfare and Supportive Services often involves submitting additional forms and documents. These documents help in assessing your eligibility and ensuring that you receive the appropriate level of assistance. The forms and documents often used along with the Nevada Division Welfare form include:

Proof of Identity - This can include a driver's license, state ID, or passport. It is used to verify the identity of the person applying for assistance.
Social Security Card - Needed for all household members included in the application. It helps in verifying Social Security numbers as required.
Proof of Income - Documents such as pay stubs, tax returns, or employer statements that show the income of all household members. This information is crucial for determining financial eligibility.
Proof of Residency - Utility bills, rental agreements, or mortgage statements can serve as proof that the applicant lives in Nevada.
Citizenship or Immigration Documents - Required to establish eligibility based on citizenship status. These can include birth certificates, naturalization papers, or immigration documents.
Bank Statements - To verify the applicant's financial resources. This could include checking and savings accounts, investments, and other assets.
Medical Bills or Expenses - If applying for medical assistance, any current medical bills or expenses might be needed to assess medical need and eligibility.
Child Support Documentation - Legal documents regarding child support payments, either received or paid, can affect eligibility and benefit levels.
Rent Receipts or Mortgage Statements - These documents help in determining housing costs for SNAP eligibility and may affect the calculation of benefits.
Unemployment Benefits Information - If any household member is receiving unemployment benefits, documentation may be needed to verify these payments.

Having the correct paperwork ready when applying for assistance through the Nevada Division of Welfare and Supportive Services can streamline the process and help to ensure that applicants receive the aid they need promptly. Each document plays an important role in building a comprehensive picture of the applicant's situation, enabling a more accurate and fair determination of eligibility for services.

Similar forms

The Nevada Division Welfare form closely mirrors the Free Application for Federal Student Aid (FAFSA) in its structure and purpose. Both are comprehensive forms used to assess eligibility for assistance, requiring detailed information on household composition, income, resources, and other financial aspects. Like the FAFSA, the Nevada Division Welfare form mandates disclosure of personal and financial information to evaluate qualification for benefits, such as Medicaid and SNAP. Each application seeks extensive data, including household income, assets, liabilities, and expenses. Furthermore, they both necessitate the provision of Social Security Numbers for verification purposes, adherence to nondiscrimination policies, and a declaration that the information provided is truthful under penalty of perjury. This similarity underscores the rigorous processes both federal and state governments use to ascertain eligibility for financial assistance programs.

Additionally, the Nevada Division Welfare form shares commonalities with the Internal Revenue Service's (IRS) Form 1040, the U.S. individual income tax return. Both require detailed financial information from applicants, including income sources, dependents, and living situation details that may affect eligibility for certain benefits or tax credits. Both forms serve as critical tools for the respective agencies to ensure applicants receive the appropriate benefits or tax considerations based on their current economic status. While the direct purpose of each form differs—one assesses tax liability and the other determines eligibility for social welfare programs—they both play pivotal roles in the financial oversight and aid distribution by government entities.

Dos and Don'ts

When completing the Nevada Division Welfare form, there are essential steps to follow and mistakes to avoid ensuring a smooth application process. Here’s what you should and shouldn't do:

Do:

Read the entire form carefully before starting to fill it out, making sure you understand every question and instruction.
Answer every question accurately. If the answer is "none," write in "NONE" to show you didn’t skip the question by mistake.
Seek help if needed. Don’t hesitate to ask a family member, friend, or a case manager from the Division of Welfare and Supportive Services (DWSS) for assistance.
Certify the correctness of your answers, understanding that your responses will be verified and that false information can lead to criminal prosecution.
Remember to disclose all income and assets, as willful concealment can have serious consequences.
Submit your application promptly to avoid delays in receiving potential benefits. Early submission ensures your application is processed within the required time frames.

Don't:

Leave any blank spaces. If a question doesn’t apply to you, make sure to fill it with “NONE” or “N/A” (not applicable).
Forget to sign and date the form. An unsigned application can lead to unnecessary delays or even be considered incomplete.
Omit any member of the household’s information. It’s crucial to include details about everyone in your household to ensure a proper assessment of your eligibility.
Ignore the importance of providing correct Social Security Numbers (SSN) for all individuals applying for assistance, as they are required for identity verification and eligibility purposes.
Provide inaccurate information about your citizenship and/or immigration status, as this could affect eligibility for various programs.

By following these guidelines, you can help ensure that your application for assistance is processed effectively and efficiently.

Misconceptions

Navigating the waters of the Nevada Division of Welfare and Supportive Services application process can be tricky due to various misconceptions floating around. Understanding the truth behind these common misunderstandings can help applicants approach the process more confidently and effectively. Here are seven of the most common misconceptions:

Only unemployed people are eligible for assistance. This isn't true. Eligibility for programs like Medicaid or SNAP isn't solely based on employment status. Factors such as income, family size, and specific needs also play crucial roles.
Applying for multiple programs complicates the process. Actually, the application is designed to allow individuals to apply for multiple types of assistance at once, streamlining the process rather than complicating it.
The application process is too long and complicated. While it's detailed to ensure accurate processing, applicants can seek help to complete it. The Division offers assistance and resources to guide applicants through every step.
Only US citizens can apply for assistance. This misunderstanding excludes a significant part of the population in need. Non-citizens meeting specific program requirements may also be eligible for certain programs.
Providing your Social Security Number (SSN) is optional. For most applicants seeking assistance for themselves, providing an SSN is a requirement, not an option. It's used for verification purposes to ensure eligibility and accurate benefit allocation.
Having a home means you’re not eligible for assistance. Homeownership in itself does not disqualify you from receiving assistance. The evaluation includes a comprehensive look at income, resources, and individual circumstances.
Dishonesty about assets or income has no real consequences. Being untruthful on your application can lead to serious repercussions, including criminal prosecution. It’s crucial to provide complete and accurate information.

Understanding these key points can make a significant difference in how you approach the application process for assistance in Nevada. Remember, the aim of these programs is to provide support to those in need, and misconceptions shouldn't stand in the way of accessing available resources.

Key takeaways

Filling out the Nevada Division Welfare form requires careful attention to detail and understanding of the assistance programs available. Here are key takeaways to ensure the process is completed correctly and efficiently:

Ensure every question is answered thoroughly. If the answer to a question is "none," explicitly write "NONE" to avoid any ambiguity.
Assistance from family, friends, or Division of Welfare and Supportive Services (DWSS) case managers is advisable if you encounter difficulties filling out the form.
Accuracy is crucial when providing information on the form, as all answers will be verified by the DWSS. This includes full disclosure of income and assets, as failure to do so may lead to legal consequences.
Applicants have specific rights and obligations, which are detailed in the attached documents to the application. It is important to review these documents to understand your entitlements and responsibilities fully.
Disclosure of Social Security Numbers (SSN) is mandatory for all applicants seeking assistance. SSNs are used to verify income, prevent duplication of benefits, and for eligibility purposes. Non-applicants or those without an SSN may affect the household's eligibility but are not obligated to provide an SSN.
For the Supplemental Nutrition Assistance Program (SNAP) applications, the process must be completed within 30 days from submission, and eligibility starts from the date the first page of the application is submitted. In cases of immediate need, actions on the SNAP application may be expedited within 7 days.

This application process also includes provisions for individuals applying for assistance due to age, disability, or specific needs such as Medicaid for aged, blind, and disabled individuals (MAABD), and the SNAP for aiding low-income households in food purchasing. Understanding and accurately responding to each aspect of the application are fundamental to receiving timely and appropriate assistance.

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