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State of Nevada Seal Division of Social Services
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DSS-Applications & Forms

Child Support

Child Care

Energy Assistance

Food (SNAP)

Financial (TANF)

Medical Program

General Use Applications & Forms
TITLE FORM UPDATED
Issue Resolution Form 6049-AG 01/29/2020
Issue Resolution Form - Spanish 6049-AGS 04/04/2019
Ways to Prove Your Citizenship 2232-EM 01/05/2023
Ways to Prove Your Citizenship - Spanish 2232-EMS 01/05/2023

Child Support

Child Support Applications & Forms
TITLE FORM UPDATED
Application for Child Support Services 4000-EC 12/02/2024
Solicitud de Manutención De Los Hijos 4000-ECS 12/02/2024
Notice of Lump Sum Payment 4004-EC 10/06/2021
Child Support Payment Authorization Form 4077-EC 02/27/2024
Declaration of Custodian of Minor Child to Change Child Support Payee 4096-EC/A 02/25/2020
Instructions for Declaration of Custodian of Minor Child to Change Child Support Payee 4096-Inst 11/04/2024
     

 

Child Care

TITLE FORM UPDATED
Application for Child Care and Development 2151-WC 10/06/2026
Solicitud para Desarrollo y Cuidado de Niños 2151-WCS 10/06/2026

Energy Assistance

Energy Assistance Applications & Forms
TITLE FORM UPDATED
Earnings Verification Form 2074-EG 01/28/2020
Instructions for Earnings Verification Form 2074-Inst 08/01/2011
Application for Energy Assistance 2824-EL 08/18/2026
Application for Energy Assistance (Vision Impaired) 2824-EL 08/18/2026
Solicitud De Asistencia Para Servicios de Energía 2824-ELS 08/18/2026
Solicitud De Asistencia Para Servicios de Energía (Discapacidad Visual) 2428-ELS 08/18/2026
EAP Designation of Authorized Representative 2840-EL 01/31/2020
EAP Designatión de Representante Autorizado 2840-ELS 11/01/2008
EAP Request for Materials 2854-EL 10/01/2008
EAP Rental Verification 2880-EL 02/04/2020
EAP Verification de Alquiler - Solo Aplica A Hogares Que Alquilan 2880-ELS 04/01/2006
EAP Intake Site Completed Application Checklist 2886-EL 01/29/2020
EAP Client Update Form 2888-EL 02/25/2020

Food (SNAP) Applications & Forms

TITLE FORM UPDATED
Statement of Applicant/Recipient Designating Burial Funds 2006-EG 01/27/2020
Declaración del Solicitante/Beneficiario Designando Fondos de Entierro 2006-EGS 01/14/2019
SNAP Affidavit of Separate Household 2008-EF 01/14/2019
SNAP Declaración de Hogar Separado 2008-EFS 01/14/2019
Income from Farm Operations & Other Self-Employment Operation Worksheet 2011A 02/05/2020
Hoja de Cálculo de Ingresos de Operaciones Agrículas Y Trabajo Autónomo 2011A-S 01/14/2019
Self-Employment Worksheet 2011-EG 02/25/2020
Hoja de Cálculo para El Trabajador Autónomo 2011-EGS 01/14/2019
Insurance Policy Worksheet 2015-EG 02/05/2020
Banking/Loan Activity - Request for Information 2016-EG 02/25/2020
Financial Aid 2020-EF 01/28/2020
VA Benefit Inquiry 2038-EE 01/28/2020
Earnings Verification 2074-EG 01/28/2020
Employer Payroll Statement 2074-EG-B 02/07/2020
Self-Employed/Tip Statement 2120-EG 02/25/2020
Declaración de Trabajador Autónomo/Propinas 2120-EGS 01/14/2019
Interface Consent 2179-EE 02/13/2020
Consentimiento de Interfaz Electrónico 2179-EES 01/14/2019
Voluntary Reduction, Withdrawal or Termination of Assistance 2248-EG 02/05/2020
La Reducción, Retirada O Terminación Voluntaria de Beneficios 2248-EGS 01/14/2019
Conference/Hearings 2254-EH 02/05/2020
Conferencias/Audiencias 2254-EHS 01/14/2019
EBT Card Issuance Authorization 2321-EGB 11/18/2024
Autorizacion de Emisión de la Tarjeta de Transferencia Electrónica de Beneficios 2321-EGBS 11/18/2024
Child Care Expense Verification Form 2329-EE 02/05/2020
Formulario de Verificación de Gastos de Cuidado de Niños 2329-EES 01/14/2019
Benefit Verification Inquiry 2339-EG 02/27/2020
Insufficient Information 2429-EEA 02/13/2020
Información Insuficiente 2429-EEAS 01/14/2019
Authorization for Release of Information 2451-EE 02/07/2020
Autorización de Divulgación de Información 2451-EES 01/14/2019
Rent/Household Composition 2488-EG 03/05/2020
Alquiler/Composición Hogar 2488-EGS 01/14/2019
Cash Contribution Verification 2506-EG 02/13/2020
Verificación de Contribución Monetaria 2506-EGS 01/14/2019
Information Needed to Process Your Application 2522-EE 05/24/2017
Información Necesaria Para Procesar Su Solicitud 2522-EES 02/07/2020
Change Report Form 2584-EG 05/13/2026
Forma para Reportar Cambios 2584-EGS 05/13/2026
Joint Ownership of Bank Account 2614-EE 01/31/2020
Cuenta Bancaria Conjunta 2614-EES 01/14/2019
Assessment and Documentation of Resources 2793-EM 02/25/2020
Evaluación Documentación de Recursos 2793-EMS 01/14/2019
Request for a Resource Assessment 2794-EM 01/29/2020
Petición de Evaluación de Recursos 2794-EMS 01/14/2019
Spousal Housing, Income and Resource Questionnaire 2796-EM 01/29/2020
Cuestionario de Vivienda, Ingresos Y Recursos del Cónyuge 2796-EMS 01/14/2019
Notification of Parental Financial Responsibility 2849-EM 02/13/2020
Notificación de Responsabilidad Financiera Parental 2849-EMS 01/14/2019
Application for Assistance 2905-EG 03/18/2026
Solicitud de Asistencia Pública 2905-EGS 03/18/2026 
Application for Food Assistance - SNAP Outreach 2935 - EG 03/25/2026
Solicitud para Asistencia Nutricional - SNAP Outreach 2935 - EGS 03/25/2026
Medical Provider ABAWD Attestation 2941 - EF 03/26/2026
Declaración de ABAWD para Proveedores Médicos 2941 - EFS 03/26/2026
Discrimination Complaint Policy and Procedures 6513-AP 02/25/2020

Temporary Assistance for Needy Families (TANF)

TANF Applications & Forms
TITLE FORM UPDATED
EBT Card Issuance Authorization 2321-EGB 02/25/2020
EBT Card Issuance Authorization (SPLW) 2321-EGBS 08/26/2019
Statement of Applicant/Recipient Designating Burial Funds 2006-EG 01/27/2020
Declaración del Solicitante/Beneficiario Designando Fondos de Entierro 2006-EGS 01/14/2019
Income from Farm Operations & Other Self-Employment Operation Worksheet 2011A 02/05/2020
Hoja de Cálculo de Ingresos de Operaciones Agrículas Y Trabajo Autónomo 2011A-S 01/14/2019
Self-Employment Worksheet 2011-EG 02/25/2020
Hoja de Cálculo para El Trabajador Autónomo 2011-EGS 01/14/2019
Insurance Policy Worksheet 2015-EG 02/05/2020
Banking/Loan Activity - Request for Information 2016-EG 02/25/2020
Financial Aid 2020-EF 01/28/2020
VA Benefit Inquiry 2038-EE 01/28/2020
Earnings Verification 2074-EG 01/28/2020
Employer Payroll Statement 2074-EG-B 02/07/2020
Self-Employed/Tip Statement 2120-EG 02/25/2020
Declaración de Trabajador Autónomo/Propinas 2120-EGS 01/14/2019
TANF Cash Benefits Program 2136-EE 01/29/2020
TANF Programas de Beneficios de Dinero 2136-EES 09/30/2013
Interface Consent 2179-EE 02/13/2020
Consentimiento de Interfaz Electrónico 2179-EES 01/14/2019
TANF Budget 2183-EE/A 09/25/2025
Voluntary Reduction, Withdrawal or Termination of Assistance 2248-EG 02/05/2020
La Reducción, Retirada O Terminación Voluntaria de Beneficios 2248-EGS 01/14/2019
Conference/Hearings 2254-EH 02/05/2020
Conferencias/Audiencias 2254-EHS 01/14/2019
Child Care Expense Verification Form 2329-EE 02/05/2020
Formulario de Verificación de Gastos de Cuidado de Niños 2329-EES 01/14/2019
Benefit Verification Inquiry 2339-EG 02/27/2020
Insufficient Information 2429-EEA 02/13/2020
Información Insuficiente 2429-EEAS 01/14/2019
Authorization to Release Information 2451-EE 02/07/2020
Autorización de Divulgación de Información 2451-EES 01/14/2019
Rent/Household Composition 2488-EG 03/05/2020
Alquiler/Composición Hogar 2488-EGS 01/14/2019
Cash Contribution Verification 2506-EG 02/13/2020
Verificación de Contribución Monetaria 2506-EGS 01/14/2019
Information Needed to Process Your Application 2522-EE

05/24/2017
Información Necesaria Para Procesar Su Solicitud 2522-EES 02/07/2020
Change Report Form 2584-EG 01/28/2020
Forma para Reportar Cambios 2584-EGS 01/14/2019
TANF Stepparent/Responsible Parent/Temporary Resident Parent Deeming Budget 2596-EE 09/25/2025
Joint Ownership of Bank Account 2614-EE 01/31/2020
Cuenta Bancaria Conjunta 2614-EES 01/14/2019
TANF Kinship Care Program 2621-EK 03/15/2022
Asistencia Temporal para Familias Necesitadas Programa de Cuidado por Parientes 2621-EKS 03/15/2022
Assessment and Documentation of Resources 2793-EM 02/25/2020
Evaluación Documentación de Recursos 2793-EMS 01/14/2019
Request for Resource Assessment 2794-EM 01/29/2020
Petición de Evaluación de Recursos 2794-EMS 01/14/2019
Spousal Housing, Income and Resource Questionnaire 2796-EM 01/29/2020
Cuestionario de Vivienda, Ingresos Y Recursos del Cónyuge 2796-EMS 01/14/2019
Notification of Parental Financial Responsibility 2849-EM 02/13/2020
Notificación de Responsabilidad Financiera Parental 2849-EMS 01/14/2019
Application for Assistance 2905-EG 03/18/2026
Solicitud de Asistencia Pública 2905-EGS 03/18/2026
Non-Custodial Parent (NCP) Form 2906-EG 02/13/2020
Formulario Sobre Padres Sin Custodia (NCP) 2906-EGS 01/14/2019
Discrimination Complaint Policy and Procedures 6513-AP 02/25/2020

Medical Programs

Medical Programs Applications & Forms
TITLE FORM UPDATED
Statement of Applicant/Recipient Designating Burial Funds 2006-EG 01/27/2020
Declaración del Solicitante/Beneficiario Designando Fondos de Entierro 2006-EGS 01/14/2019
Income from Farm Operations & Other Self-Employment Operation Worksheet 2011A 02/05/2020
Hoja de Cálculo para El Trabajador Autónomo 2011A-S 01/14/2019
Self-Employment Worksheet 2011-EG 02/25/2020
Hoja de Cálculo para El Trabajador Autónomo 2011-EGS 01/14/2019
Insurance Policy Worksheet 2015-EG 02/05/2020
Banking/Loan Activity - Request for Information 2016-EG 02/25/2020
Financial Aid 2020-EF 01/28/2020
VA Benefit Inquiry 2038-EE 01/28/2020
Medical Assistance for the Aged, Blind and Disabled (MAABD) Addendum 2059-EM 05/15/2026
Addenda de Asistencia Médica para Ancianos, Ciegos y Discapacitados (MAABD) 2059-EMS 05/15/2026
Parental Reimbursement Questionnaire 2069-EM 02/13/2020
Cuestionario de Reembolso Parental 2069-EMS 01/14/2019
Earnings Verification 2074-EG 01/28/2020
Employer Payroll Statement 2074-EG-B 02/07/2020
Self-Employed/Tip Statement 2120-EG 02/25/2020
Declaración de Trabajador Autónomo/Propinas 2120-EGS 01/14/2019
Interface Consent 2179-EE 02/13/2020
Consentimiento de Interfaz Electrónico 2179-EES 01/14/2019
Voluntary Reduction, Withdrawal or Termination of Assistance 2248-EG 02/05/2020
La Reducción, Retirada O Terminación Voluntaria de Beneficios 2248-EGS 01/14/2019
Conference/Hearings 2254-EH 02/05/2020
Conferencias/Audiencias 2254-EHS 01/14/2019
Child Care Expense Verification Form 2329-EE 02/05/2020
Formulario de Verificación de Gastos de Cuidado de Niños 2329-EES 01/14/2019
Benefit Verification Inquiry 2339-EG 02/27/2020
Insufficient Information 2429-EEA 02/13/2020
Información Insuficiente 2429-EEAS 01/14/2019
Authorization for Release of Information 2451-EE 02/07/2020
Autorización de Divulgación de Información 2451-EES 01/14/2019
Request for Prior Medical Assistance 2468-EE 02/13/2020
Rent/Household Composition 2488-EG 03/05/2020
Alquiler/Composición Hogar 2488-EGS 01/14/2019
Cash Contribution Verification 2506-EG 02/13/2020
Verificación de Contribución Monetaria 2506-EGS 01/14/2019
Medical/Insurance Subrogation 2511-EE 01/14/2019
Subrogación Médica/de Seguro 2511-EES 01/14/2019
Information Needed to Process Your Application 2522-EE 05/24/2017
Información Necesaria Para Procesar Su Solicitud 2522-EES 02/07/2020
2525-EE Designation of Authorized Representative ADA.pdf 2525-EE 01/01/2020
2525-EES Designation of Authorized Representative ADA.pdf 2525-EES 01/01/2020
Change Report Form 2584-EG 01/28/2020
Forma para Reportar Cambios 2584-EGS 01/14/2019
Joint Ownership of Bank Account 2614-EE 01/31/2020
Cuenta Bancaria Conjunta 2614-EES 01/14/2019
Assessment and Documentation of Resources 2793-EM 02/25/2020
Evaluación Documentación de Recursos 2793-EMS 01/14/2019
Request for a Resource Assessment 2794-EM 01/14/2019
Petición de Evaluación de Recursos 2794-EMS 01/14/2019
Spousal Housing, Income and Resource Questionnaire 2796-EM 01/14/2019
Cuestionario de Vivienda, Ingresos Y Recursos del Cónyuge 2796-EMS 01/14/2019
Notification of Parental Financial Responsibility 2849-EM 02/13/2020
Notificación de Responsabilidad Financiera Parental 2849-EMS 01/14/2019
Application for Assistance (MAABD-SNAP) 2920-EM 07/16/2026
Aplicacion Para Asistencia (MAABD-SNAP) 2920-EMS 07/16/2026
Application for Health Insurance 2960-EG 06/22/2026
Solicitud de Seguro de Salud 2960-EGS 06/22/2026
Application for Health Insurance-Additional Member 2961-EG 10/14/2024
Solicitud de Seguro de Salud-Miembros adicionales del Hogar 2961-EGS 10/14/2024
Application for Presumptive Eligibility for Medicaid 2990-EM 05/15/2026
Solicitud de Elegibilidad Presunta de Medicaid 2990-EMS 05/15/2026
Admit/Discharge/Death Notice 3058-SM 09/25/2025
Discrimination Complaint Policy and Procedure 6513-AP 02/25/2020
Peace of Mind 2025 Brochure 10/07/2025
Peace of Mind 2025 (Spanish) Brochure 10/07/2025