Blank Nevada Welfare Division PDF Template

Division of Welfare and Supportive Services

Application for Assistance

“Working for the Welfare of ALL Nevadans”

Programs You May Apply For:

Food Assistance from the Supplemental Nutrition Assistance Program (SNAP) helps people buy food.

Temporary Assistance for Needy Families (TANF) helps families with children meet their basic needs with cash assistance.

Time Frames

SNAP benefits are processed within 30 days from the date of the application. If your household has little or no income, you could receive SNAP benefits within 7 days from the date of your application. SNAP benefits are paid from the date of the application.

TANF benefits are paid from the date of approval or 30 days from the date of the application, whichever is sooner. TANF applications are processed within 45 days from the application date unless there are unusual circumstances.

Denial of benefits for one program does not automatically affect the decision on another program you may be applying for.

SNAP Expedite Rules

The following households are entitled to expedited service and should receive SNAP benefits within 7 days:

Households with less than $150 in monthly gross income and no more than $100 in liquid resources;

Migrant or seasonal farm worker households who are destitute, provided their liquid resources do not exceed $100;

Households with combined monthly gross income and liquid resources less than the household’s monthly rent or mortgage and utilities.

Social Security Numbers

You will be asked to provide Social Security Numbers (SSN) for all persons (including yourself) who are applying for assistance, pursuant to Title 42 USC 1320b-7 and is authorized under the Food and Nutrition Act of 2008 (formerly the Food Stamp Act), as amended 7 U.S.C. 2011-2036. Providing or applying for a SSN is voluntary. For SNAP, any person who wants assistance but does not want to give information about his or her SSN will not be eligible for benefits. Other family or household members may still get benefits if they are otherwise eligible. For TANF, if a required household member fails or refuses to provide an SSN without good cause, the entire household will be ineligible for TANF benefits. This includes all individuals whose income and needs are used to determine eligibility for the TANF program.

SSNs are used to verify your household’s income and resources and to conduct computer matching with other agencies such as the Social Security Administration, Employment Security Division, Child Support Enforcement Programs and the Internal Revenue Service. It is also used to gather workforce information, investigations, recover overpaid benefits and to ensure duplicate benefits are not received.

Citizenship/Immigration Status

You will be required to provide information about the citizenship and/or immigration status for all persons (including yourself) who are applying for assistance. For SNAP, if any of these persons do not want to give us information about his/her citizenship and/or immigration status, he/she will not be eligible for benefits. Other family or household members may still receive benefits if they are otherwise eligible. For TANF, if a required household member fails or refuses to provide verification of their status, the entire household will be ineligible for TANF benefits. Qualified Non-Citizen status is verified with the United States Citizenship and Immigration Service (USCIS) for eligibility purposes. Information on non-applicants or non-qualified non-citizens will not be shared with USCIS.

Where do I mail my completed application?

Send or submit your complete, signed application to the address below. Eligibility determinations will be based on rules and requirements which pertain to the program you are applying for. We will notify you if you are eligible or not, or give you further instructions for completing your application.

State of Nevada

Division of Welfare and Supportive Services

P.O. Box 15400

Las Vegas, NV 89114-5400

What if I need help with this application?

Phone: 1-800-992-0900 ext 47200  Southern Nevada (702) 486-1646  Northern Nevada (775) 684-7200

Email: welfare@dwss.nv.gov  Online: https://dwss.nv.gov

In person: Visit our website or call 1-800-992-0900 ext 47200 to find a local DWSS District office

Language Interpreter: Call 1-800-992-0900 ext 47200 or TTY 1-800-326-6888

Applicant information, please keep this page for your records.

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

(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.

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.

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.

*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

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.

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.

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To get SNAP (food assistance) and/or TANF (cash assistance), most people are required to come into the office for a face-to-face

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.

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?

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

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Employer’s address? ____________________________________________________________________________________

If self-employed, please list any business related expenses. ____________________________________________________

____________________________________________________________________________________________________

Employer’s address?

If self-employed, please list any business related expenses. ____________________________________________________

____________________________________________________________________________________________________

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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.

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PERSONAL PROPERTY

MISCELLANEOUS

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.

30. Have you or any person(s) in your household sold, traded or given away any money, vehicles, property or other resources, or

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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.

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