STATE OF NEVADA RICHARD

DEPARTMENT OF HEALTH AND HUMAN SERVICES WHITLEY, MS

DIVISION OF WELFARE AND SUPPORTIVE SERVICES Director

STEVE ROBERT
SISOLAK THOMPSON
Governor Administrator

Electronic Application Summary

This document is a summary of the information you provided in your electronic or telephonic application. Please review the information for accuracy and
if anything is incorrect notify the agency immediately.

You Have Applied for the Following Programs

Food Assistance (SNAP)
Medical Assistance (Family Medical Coverage and Nevada Check-Up)

● SNAP benefits are issued within 30 days from the date the agency receives your application. If your household has little or no income, you
could receive your SNAP benefits within 7 days from the date the agency receives your application. Once approved, your initial issuance will be
calculated from the date the agency received your application to the end of that first month.

● Medical assistance, if approved, is issued for the entire month regardless of the date you submit your application. Exception: Nevada Check-
Up and Qualified Medicare Beneficiaries are eligible the next administrative month. Medical assistance will be processed within 45 days from the
date the agency receives your application, unless there are unusual circumstances.

Denial of benefits for one program does not automatically affect the decision of other programs for which you have applied.

What We Need From You

You may be required to provide proof of identity, citizenship, household relationship, any money received by your household, resources owned by your
household, or expenses incurred by the household. If additional proof is required, you will be notified by the agency in writing and given a period of time
to provide the information.

Interview Requirement
Food Assistance
You have applied for Food Assistance. You will be required to complete an interview. This interview can be completed on the telephone or in person at
the local office. You will receive an appointment slip stating the time and place of the appointment.

If You Have Questions

You can check the status of your benefits online by clicking the “ACCESS Nevada” link at dwss.nv.gov.
You may call Customer Service:
● Southern Nevada, call (702) 486-1646
● Northern Nevada, call (775) 684-7200
● Rural Nevada, call (800) 992-0900, extension 47200
To find a listing of local offices, click the “Contact Us” link at dwss.nv.gov.

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 Reference Codes

Relationship Codes (Code and Description)

01 Self
02 Spouse
03 Parent of Applicant's Child
04 Parent of Applicant {Natural, Adoptive, or Step}
05 Child
06 Grandchild
07 Nephew or Niece
08 Sibling
09 First or Second Cousin
10 Other Relative
11 Boarder
12 Friend
13 Unborn Child
15 Step Child
16 Step Grandchild
17 Step Nephew or Niece
18 Step Brother or Sister
19 Other Specified Adult Relative
20 Foster Child
21 Required Member Not Related to the Head of Household
25 Child Unrelated to Applicant
26 Unborn Child of Another Household Member
30 Step Parent
31 Domestic Partner

Race and Ethnicity Codes (Code and Description)

A Asian (Non-Hispanic)
B Black (Non-Hispanic)
C American Indian or Alaskan Native and White (Hispanic/Latino)
D Asian And White (Hispanic or Latino)
E Black or African American and White (Hispanic/Latino)
F American Indian/Alaska Native & Black/African American (Hispanic/Latino)
I American Indian or Alaskan Native (Non-Hispanic)
J American Indian or Alaskan Native & White (Non-Hispanic)
L Asian and White (Non-Hispanic)
M Black or African American and White (Non-Hispanic)
N American Indian/Alaskan Native & Black/African American (Non-Hispanic)
P Asian (Hispanic or Latino)
Q Black Hispanic
R American Indian or Alaskan Native Hispanic
T White Hispanic
U Pacific Islander or Native Hawaiian (Non-Hispanic)
V Pacific Islander or Native Hawaiian (Hispanic/Latino)
W White (Non-Hispanic)
Y 2 or More Other Race Combinations (Hispanic/Latino)
Z 2 or More Other Race Combinations (Non-Hispanic)

Marital Status (Code and Description)

D Divorced
L Legally Separated
M Married
N Never Married
P Separated
W Widowed

Last Grade Completed (Code and Description)

00 No Formal School
01 1st Grade
02 2nd Grade
03 3rd Grade
04 4th Grade
05 5th Grade
06 6th Grade
07 7th Grade
08 8th Grade
09 9th Grade
10 10th Grade
11 11th Grade
12 12th Grade
13 Completed GED
14 Post Secondary Vocational/Skills Training
15 One Year College Completed
16 Two Year College Completed
17 Three Year College Completed
18 College Graduate
19 Postgraduate

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3
 HOUSEHOLD INFORMATION

Application Date: 09/05/2022

M
G
E
e U.S. F C
A Social Month/ D
Name n Date of Marital Citizen Last Grade O A
Relationship g Security Ethnicity Year I
(First, Middle, Last, Suffix) d Birth Status or Completed O S
e Number Completed C
e National D H
A
r
L
DAJAH MICHELLE KING 01 F 03/23/1999 23 N ***-**-1018 Y N 11 06/2016 X X

Are you homeless? Yes X No

Home Address City State Zip Code

4400 SOUTH JONES BOULEVARD LAS VEGAS NV 89103

3114
Mailing Address (if different from City State Zip Code
your home address)

4400 SOUTH JONES BOULEVARD LAS VEGAS NV 89103

3114
Home Phone: Cell Phone: Message Phone: Work Phone:

Email:

SPECIAL ACCOMMODATIONS
Special Accommodations Needed? Yes X No

What do you need?

Spoken Language ENGLISH

Interpreter Needed Yes No

Buy, prepare, and eat with others? X Yes No

If "NO", list who buys their food separately
First Name Last Name

Have You Or Any Person In Your Household Received TANF, Medical Assistance, Food Assistance Or Indian
Commodities In Nevada Or Any Other State?
Name DOB Type of Benefit Last Received State

SSN APPLIED DATE

Name DOB SSN Applied Date

DATE OF NV RESIDENCE
Date Intent To Reside?
08/01/2011 Y

AMERICAN INDIAN/ALASKAN NATIVE

Name DOB Tribe
DAJAH MICHELLE KING 03/23/1999 N/A

FOR OFFICE USE ONLY - EXPEDITED SERVICE SCREENING: HOUSEHOLD ELIGIBLE FOR EXPEDITED
SERVICE?
X Yes No Date: 09/05/2022

4
 CASE INFORMATION

AUTHORIZED REPRESENTATIVE

Name Programs Telephone # Address Emergency

Contact?

EMERGENCY CONTACT
Name Relationship Daytime Telephone # Address

5
 HOUSEHOLD INFORMATION - DEMOGRAPHICS

DISABILITY
Disability
Name DOB Type Of Disability Disability Begin Date

NON-CITIZEN INFORMATION
Immigration Country Expiration Date Of
Name DOB Document Type Document Number
Status of Origin Date Entry

SCHOOL ATTENDANCE
School
Expected
Name DOB Student Status Type of School School Name
Completion Date

PREGNANCY
How Many Babies
Name DOB Due Date
Are Expected?

LONG TERM CARE

In Hospital, Nursing Home or Medical Facility Currently Or In The Past
Name DOB Date Entered Date of Discharge Facility Name

ALIASES
Name DOB ALIAS

6
 HOUSEHOLD INFORMATION – HOUSEHOLD COMPOSITION

MEMBERS OUTSIDE THE HOUSEHOLD DETAIL

Name DOB Social Security Number Marital Status Is Blind/Disabled?

REPORTED TAX HOUSEHOLD INFORMATION

Primary Filer Joint Filer Claimed Tax Dependent(s)
Name DOB Name DOB Name DOB

MEMBER TAX FILING STATUS

Name DOB Status
DAJAH MICHELLE KING 03/23/1999 PRIMARY FILER

7
 STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES

NON-CUSTODIAL PARENT (NCP) FORM

When applying for TANF and/or Medicaid assistance, the law requires you to cooperate with Child Support Enforcement (CSE) to establish paternity to
get child support and/or medical support owed to you and/or any child(ren) that you are applying for. This may include genetic testing. If the test proves
the person you named is not the father, you may be required to pay the cost of the test. You are also responsible for providing all available information
requested by the CSE Program such as certified copies of divorce decrees and/or support orders, birth certificates and photographs of the absent
parent.

The CSE Program locates absent parents and/or sources of income and assets, establishes and enforces financial and medical support, reviews and
adjusts existing child support orders, and collects and distributes financial and medical support payments. If you are requesting medical assistance
only, you may request in writing you only want medical support services.

The CSE Program has sole discretion in determining which legal remedies are used in pursuing support and cannot guarantee success. CSE may
request assistance of another state, and thereby, be subject to the laws of that state. CSE does not provide services involving custody, visitation or
unpaid medical bills. CSE may close your case when your case meets closure rules established by federal and state regulation.

The CSE Program represents the State of Nevada when providing services and no attorney-client privilege exists. CSE is authorized to endorse
and cash payments made payable to you for support payments and may collect past-due support by intercepting an IRS tax refund or other federal
payment. If a tax intercept occurs, the CSE Program has the authority to hold a joint tax refund for a period of six (6) months before distributing the
funds. No interest is paid on the held funds. Funds collected from a tax intercept are applied first to pay off any past-due support assigned to the State
of Nevada. A nonrefundable fee is deducted by the federal government of any tax or federal payment intercepted by the CSE Program.

Good cause for not cooperating in pursuing child support or paternity may be allowed. If you do not cooperate with CSE and good cause has not been
determined, your household will be ineligible for TANF and you will be ineligible for Medicaid. Good cause for not cooperating will be considered if you
request it in writing. Examples of good cause are as follows:
● The child was conceived as a result of rape or incest.
● Legal proceedings for adoption of the child are pending before a court.
● You are being assisted by a public or licensed private social service agency to decide whether to keep or relinquish the child for adoption (no
longer than three (3) months).
● Your cooperation in establishing paternity or securing support will result in physical or emotional harm to yourself or the child(ren).

You must provide your case manager with verification within twenty (20) days after claiming good cause. You will receive written notification of the good
cause decision. If you are found to have good cause for not cooperating, CSE will NOT attempt to establish paternity or collect child support.

Do you wish to claim good cause at this time?

YES, I wish to claim good cause.

NO, I do not wish to claim good cause at this time.

I have read and agree. Initials: D M K

Your Signature Print Name Date Telephone Number

You must report changes whenever a name change occurs; you have a new address or telephone number for home or work; you hire a private attorney
or collection agency; another child support or paternity legal action is filed; you file for divorce; you receive support payments directly from the absent
parent; you have a new address, telephone number, employment or health insurance for the absent parent; a child(ren) no longer lives with you; a
child(ren) is still in high school after age 18; a child(ren) becomes disabled before age 18; a child(ren) comes to live with you or you birth another child;
a child marries, is adopted, joins the armed forces or is declared an adult by court order.

You are responsible for repayment of support amounts received in error, including payments from an IRS tax refund, which are adjusted by the IRS. If
you fail to enter into a repayment agreement with the CSE Program, the outstanding balance may be reported to a credit reporting agency and money
collected on your behalf by the CSE Program may be withheld for repayment. Additionally, legal action may be initiated against you.

8
 NEVADA STATE DIVISION OF WELFARE AND
SUPPORTIVE SERVICES NON-CUSTODIAL PARENT
(NCP) FORM

NON-CUSTODIAL PARENT INFORMATION

CUSTODIAN INFORMATION
Relationship Previous Public
Custodian Name SSN DOB Where
To Child(ren) Assistance

NON-CUSTODIAL PARENT INFORMATION

Social Date Last
Name Address (City, Home Phone /
Security Seen Or Ethnicity
(First, Middle, Last, Suffix) State, Zip) Cell Phone
Number Contacted

Birth City
Sex Hair Color Eye Color Weight Height Disabled DOB If Deceased, DOD
And State

If Deceased, Mother Was The Mother

Date Of Place Of Date Of
Place Of Married Divorced Place Of Divorce Married To
Marriage Marriage Divorce
Death To NCP Someone Else

Existing Child Support Court Order City And State

INFORMATION ON THE CHILDREN FOR THIS ABSENT PARENT

Child’s Social
Child’s Last Name Child’s First Name Child's Middle Name Child’s Date Of Birth
Security Number

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 HOUSEHOLD INFORMATION – OTHER EXISTING BENEFITS

SPOUSE/PARENT/INDIVIDUAL IS AN HONORABLY DISCHARGED VETERAN OR ACTIVE DUTY MILITARY

MEMBER
Name DOB

WORKED FOR THE RAILROAD OR BEEN A CITY, COUNTY, STATE OR FEDERAL GOVERNMENT EMPLOYEE
Name DOB

MIGRANT OR SEASONAL FARM WORKER

Name DOB

FOSTER CARE DETAILS

Age Left
Name DOB State Medicaid?
Program

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 HOUSEHOLD INFORMATION – DECLARATIONS

Have you or any person living in your home been convicted of a felony drug offense on or after August 22,
1996?
Name DOB When Where

Are you or any person living in your home currently participating or have participated in a drug addiction or
alcohol treatment program?
Name DOB Date Entered Date Completed Facility Name Facility Address Facility Phone

Are you or any person living in your home currently wanted by law enforcement or is anyone in the household
fleeing to avoid felony prosecution or jail time?
Name DOB Why

Are you or any person living in your household currently disqualified for an IPV?
Name DOB When Where

Has anyone in your household been convicted of trading SNAP benefits for guns, ammunition, or explosives on
or after September 22, 1996?
Name DOB

Has anyone in your household been convicted of receiving duplicate SNAP benefits in any state on or after
September 22, 1996?
Name DOB

Has anyone in your household been convicted of buying or selling SNAP benefits over $500 on or after
September 22, 1996?
Name DOB

Is anyone in your household currently violating conditions of probation or parole?

Name DOB

Have you read and answered all the questions in this section correctly? Yes No X Not Answered
Answering “No” will not prevent you from completing this application. The Department will follow-up and collect missing information after you
submit this application.

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 HOUSEHOLD INFORMATION – HEALTH INSURANCE AND MEDICAL EXPENSES

MEDICAL/HEALTH INSURANCE
Insurance Group/Policy Coverage
Policy Holder’s Name DOB Type Of Coverage Covered Persons
Company Name Number Begin Date

Premium
Name DOB Monthly Amount

MEDICAL/HEALTH INSURANCE NOT PURSUED

Name DOB Employer

MEDICARE
Railroad Retirement
Name DOB Medicare Claim #
Board Number

PRIOR MEDICAL
Name DOB Prior Medical What Months

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 INCOME

UNEARNED INCOME
Name DOB Type Monthly Amount Is Tribal? Frequency

JOB INCOME
Hours Worked
Name DOB Hourly Pay Pay Frequency Tips Per Month
Per Week

Employer Information
Employer’s Name Employer’s Telephone Employer’s Address

SELF-EMPLOYMENT
Monthly
Name DOB Business Type Is Tribal? Business Start Date Business Expenses
Gross Income

OTHER INCOME
Name DOB Type Is Tribal? Amount Frequency Last Received Date

DEDUCTIONS
Name DOB Type Frequency Monthly Amount

STRIKE
Name DOB

REGISTERED WITH A TEMPORARY EMPLOYMENT SERVICE/AGENCY

Name DOB Name Of The Agency Agency Phone Number

LOSS OF EMPLOYMENT IN PAST 60 DAYS

Employer Information
Name DOB
Employer’s Name Employer’s Telephone Employer’s Address

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 EXPENSES

RENT

Includes Heating
Name DOB Monthly Rent Frequency Includes Utilities?
and Cooling?

Landlord's Name How Much Does

Is The Rent Subsidized? Amount Subsidized Is The Rent Shared?
(Name - Phone - Address) This Person Pay?

UTILITY EXPENSE
Heating Or
Name DOB Utilities Paid
Cooling

HOMEOWNER EXPENSE
Association
Name DOB Mortgage Frequency Frequency
Fees

Homeowner's
Name DOB Frequency Taxes Frequency
Insurance

Name DOB Lot/Space Rent Frequency Other Frequency

MEDICAL EXPENSE
Name DOB Type Amount

SUPPORT DEEMED EXPENSE

Name DOB Type Amount Frequency

DEPENDENT CARE EXPENSES

Name DOB

Provider Amount Monthly

Reason Provider For Whom Subsidized Frequency
Number Paid Amount

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 RESOURCES

BANK
Last Four
Owner DOB Type Bank Digits of Current Balance Joint Account?
Account Number

VEHICLES
Owner DOB Type Year- Make- Model Fair Market Value Amount Owed

LIFE INSURANCE/TRUSTS/BURIALS
Cash
Type of Begin Insurance Face Amount Policy
Owner DOB Surrender
Coverage Date Company Value Owed Number
Amount

REAL PROPERTY
Owner DOB Type Market Value Amount Owed Listed For Sale Income Producing

LUMP SUM AMOUNT

When was the
Owner DOB Type Amount Received
Amount Received

TRANSFERRED RESOURCES
Have you or any person(s) in your household sold, traded or given away money, vehicles, property or other resources,
closed any bank accounts or purchased any annuities in the last 3 months (SNAP) or the last 60 months (other programs)?
Who DOB Transferred Resource When Value At Transfer

OTHER
Owner DOB Type Value Amount Owed

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 Simplified Applications

Applicant must provide at a minimum their name, address and signature to submit an application. However, providing as much information as possible
through the application process may reduce the wait time for case processing.

Expedited SNAP
Households (HHs) entitled to expedited service are:

• HHs with less than $150 in monthly gross income and no more than $100 in liquid resources;
• migrant or seasonal farm worker HHs who are destitute, provided their liquid resources do not exceed $100;
• HHs with combined monthly gross income and liquid resources less than the HH's monthly rent or mortgage and utilities.

Health Information Opt-Out

Nevada law mandates that “a person who is a recipient of Medicaid or insurance pursuant to the Children’s Health Insurance Program may not opt out
of having his or her individually identifiable health information disclosed electronically" [Nevada Revised Statute 439.538]. When a patient is no longer a
Medicaid recipient, it is the patient’s responsibility to change their consent choice. At any time, you may revoke your consent by signing a new consent
form and giving it to your doctor. These forms are available at your doctor’s office.

American Indians or Alaska Natives (AI/AN)

Tribal members who enroll in Medicaid, Nevada Check Up and through the Nevada Health Link can also get services from the Indian Health Services,
Tribal Health Programs or Urban Indian Health Programs.

If you or your family members are American Indian or Alaska Native, you may not have to pay premiums or cost sharing. We will ask additional
questions to make sure you and your family get the most help possible. Tribal Affiliation Cards are required.

Nevada Public Health Foundation (NPHF)

Utilizing TANF funds, DWSS through the Nevada Public Health Foundation (NPHF), has developed a class to target pregnant and parenting teens
receiving TANF cash assistance. Teen parents receiving TANF benefits and services are known as STARS (Supporting Teens Achieving Real-life
Success) participants. This class has been expanded to include other pregnant and parenting teens receiving other forms of assistance such as SNAP
and Child Welfare. This one-day class places emphasis on employment, success in the workplace, decision-making, money management and health,
such as birth control and sexually transmitted diseases.

In addition, Community Action Teams, an entity of the Nevada Public Health Foundation, conduct community assessments of teen pregnancy and
its prevention and identify potential methods for reducing teen pregnancy through abstinence-based programs. Youths, parents, business, churches,
health care providers, law enforcement, schools and other organizations are encouraged to serve on the Community Action Teams. Men of all ages are
also encouraged to serve as positive role models, reinforcing the postponement of sexual involvement message.

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. 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. Qualified Non-Citizen status is verified with the
United States Citizenship and Immigration Service (USCIS) for eligibility purposes. Information on non-applicants or non-citizens will not be shared with
USCIS.

Social Security Number (SSN)

Providing an SSN is optional; however, all household members who do not provide an SSN may be denied benefits. The collection of the SSN is
authorized under the Food and Nutrition Act and Title 42 USC 1320b-7. Providing or applying for an SSN is voluntary.

You will be asked to provide an SSN for all persons (including yourself) who are applying for assistance. Any person who wants assistance but does
not want to provide information about his or her SSN may not be eligible for benefits. Other family or household members may still get benefits if they
are otherwise eligible. If you are applying for emergency Medicaid because of your immigration status, you do not need to give us information about
your SSN if you do not have one.

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 received.

The Division of Welfare and Supportive Services makes every endeavor to protect your privacy online. See the Nevada Internet Privacy Policy, NRS
603A - Restrictions on Transfer of Personal Information Through Electronic Transmission, and NRS 603A.210 and 603A.220 - Security of
Personal Information. This web site uses industry-standard SSL encryption.

Tri-Agency Guidance Opt-Out Process

The Tri-Agency Guidance opt-out process includes:

• HH members may choose not to seek benefits and will not be required to answer questions about SSNs, or provide citizenship/immigration
information.
• HH members who are seeking benefits must supply information about SSNs and citizenship or immigration status.
• The amount of benefits will depend on the number of people requesting benefits, but eligible household members who apply will be able to get
benefits even though some people in the household are not seeking benefits.
• Household members who are not seeking benefits will be required to provide their financial information if it is needed to determine eligibility and
benefit amount for persons who are applying.
Guidance on conforming to the tri-agency guidance in online applications is available at:

16
https://fns-prod.azureedge.net/sites/default/files/Tri-Agency_Guidance_Memo-021811.pdf

I have read and agree. Initials:D M K

Equal Opportunity/Non-Discrimination Statement

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 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 program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: https://
www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer, 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:

Food Assistance (SNAP) Cash Assistance (TANF) & Health Coverage (Medicaid)

Mail: U. S. Department of Agriculture Mail: Centralized Case Management Operations

Director, Office of Adjudication U.S. Department of Health and Human Services
1400 Independence Avenue, SW 200 Independence Avenue, SW
Washington, DC 20250-9410 Room 509F, HHH Building
Washington, D.C. 20201

Phone: (866) 632-9992; (202) 260-1026 Phone: (800) 368-1019; (202) 619-0403
TTY: (800) 877-8339; (866) 377-8642 (Relay Voice) TTY: (800) 537-7697; (202) 619-3257
Fax: (202) 690-7442 Fax: (202) 619-3818
Email: program.intake@usda.gov Email: OCRComplaint@hhs.gov
Online: https://www.ascr.usda.gov/filing-program- Online: http://www.hhs.gov/ocr/office/file
discrimination-complaint-usda-customer

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 .

This institution is an equal opportunity provider.

I have read and understand the information on Non-Discrimination. Initials D M K

Your Responsibilities – If You Are Applying for: Health Coverage

You must report to the Health Coverage Assistance program if information listed on this application changes. You must report any changes by
contacting customer service by the 5th of the following month; individuals approved under the aged, blind, or disabled program have until the 10th of
the following month to report changes. Changes may affect your household’s eligibility.

Nevada law mandates that “a person who is a recipient of Medicaid or insurance pursuant to the Children’s Health Insurance Program may not opt out
of having his or her individually identifiable health information disclosed electronically” (NRS 439.538). When a patient is no longer a Medicaid recipient,
it is the patient’s responsibility to change their consent choice. At any time, you may revoke your consent by signing a new consent form and giving it
to your doctor. These forms are available at your doctor’s office.

I have read and understand the Health Coverage Assistance Responsibilities. Initials D M K

Your Responsibilities – If You Are Applying for: Food Assistance

You are required to report all changes in your household from the date you submit your application to the day of your interview. Once SNAP benefits
are approved, you must report required changes within 10 days from the date the change happened based on your household’s specific reporting
requirements. Your approval notice will specify your reporting requirements.

If your household is designated as a Change Status Reporting Household, you will be required to report: change of physical or mailing address; the
birth of a child or other change in the number of people in your home, including the temporary or permanent absence of any household member for 30
days or more; changes in school attendance or student status; increases or decreases in living expenses; changes in marital or employment; increases
or decreases in income or resources from any source; and any other change which may affect your household benefits.

If your household is designated a Simplified Reporting Household, you must report when your household's income exceeds 130% of the federal poverty
level for your household size; you will be notified of this amount at approval. Your case manager may request additional proof of any changes reported,
which must be received by a certain date to continue your eligibility or avoid an overpayment or underpayment of benefits.

SNAP allows certain household expenses like rent, mortgage, property taxes, homeowner’s insurance, utility expenses, child/dependent care and child
support paid by the household as a deduction to determine the amount of SNAP benefits your household is eligible for as long as the expense is reported

17
and verified. Medical expenses over $35.00 are allowed if there is an elderly or disabled person applying for benefits. If you do not verify an expense
listed on the application, it will be considered that you do not want to receive a deduction for the unverified expense.

I have read and understand the information on SNAP Responsibilities. Initials D M K

Electronic Benefits Transfer (EBT) Card: Cash Assistance and Food Assistance
Any unused TANF benefits will be removed from my card 6 months after issuance and applied to any outstanding TANF debt. It is illegal to misuse, sell,
attempt to sell, trade, and purchase or alter an EBT card. It is unlawful to access TANF benefits from ATM machines located in, or purchase items or
services in the following locations: casinos, gaming establishments, liquor stores, and retail establishments providing adult entertainment.

Federal law states the intended period of use for SNAP benefits is 9 months from the date of issuance. The DWSS is required to remove any unused
SNAP benefits from an account 274 days after the benefit was issued and return them to the Federal government. Unused benefits are frozen 269
days after their issuance. If the client, or any adult member of the client’s household, has any outstanding SNAP debt, the frozen benefit will be applied
towards the SNAP debt.

I have read and understand the information on Electronic Benefits Transfer (EBT) card. Initials D M K

Work Requirements: Cash Assistance and Food Assistance

To receive food (SNAP) and/or cash (TANF) assistance I may be required to participate in work programs. Failure to do so may result in a loss or decrease
in benefits.

If I or another household member voluntarily quits a job or reduces work hours, it may be considered as a failure to meet work requirements.

Disqualifications for not meeting SNAP work requirements are as follows:

• First Violation: 1 month or until compliant
• Second Violation: 3 months or until compliant
• Third Violation: 6 months or until compliant.

My household may lose TANF benefits for three months if I fail to follow my Personal Responsibility Plan.

I have read and understand the information on Work Requirements. Initials D M K

Third Party Liability - Health Coverage

The following is an eligibility requirement to receive Health Coverage Assistance benefits:
• If anyone on this application receives Health Coverage Assistance benefits, I give the Medicaid agency the right to pursue and get money from any other
health insurance, insurance, legal settlements, or other third party that may be liable for the medical services paid by Medicaid; and
• I give the Medicaid agency the right to pursue and get child and medical support from a spouse or a parent; and
• I agree my household members will cooperate with the Medicaid agency to obtain any money from insurance companies, legal settlements and third
parties and will give DHHS notice of any settlements or legal action.

I have read and understand the information on Third Party Liability. Initials D M K

Overpayments, Case Reviews & Investigations: Cash Assistance Food Assistance Health Coverage
By signing this application, you authorize the Department of Health and Human Services to investigate your household's circumstances used to determine
eligibility for benefits. Information provided by the applicant, beneficiary, or authorized representative in connection with this application will be subject
to verification by Federal, State or local officials to determine if the information is factual. If the information is determined to be incorrect, your SNAP,
TANF, or Health Coverage benefits may be denied, terminated, or reduced if you do not cooperate with an investigation. Making false or misleading
statements, misrepresenting, concealing or withholding facts used to determine eligibility may also result in future program disqualification and criminal
prosecution per state and federal laws.

You are responsible for repayment of all benefits you were not entitled to receive. Health Coverage benefits and all costs associated with administering
the program, including capitation fees paid to managed care organizations on your behalf are part of this repayment.

I have read and understand the information on Overpayments, Case Reviews and Investigations. Initials D M K

Program Violations: Cash Assistance Food Assistance

Individuals found guilty of an intentional program violation in TANF and/or SNAP will be disqualified from program benefits as follows: first violation - 12
months; second violation - 24 months; third violation - PERMANENTLY disqualified. The unlawful use of SNAP is punishable by a fine up to $250,000,
imprisonment for up to 20 years or both.

If a court of law finds you guilty of using or receiving SNAP benefits in a transaction involving the sale of a controlled substance, you will not be eligible
for benefits for two years for the first offense, and permanently for the second offense.

If a court of law finds you guilty of having used or received SNAP benefits in a transaction involving the sale of firearms, ammunition or explosives, you
will be permanently ineligible to participate in the Program upon the first occasion of such violation.

If a court of law finds you guilty of having trafficked SNAP benefits for an aggregate amount of $500 or more, you will be permanently ineligible to participate
in the Program upon the first occasion of such violation.

If you are found to have made a fraudulent statement or representation with respect to the identity or place of residence in order to receive multiple SNAP
benefits simultaneously, you will be ineligible to participate in the Program for a period of 10 years.

I have read and understand the information on Program Violations. Initials D M K

Medicaid Estate Recovery Notification of Program Operation

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Please be advised that if you are applying for or receiving benefits from the Medicaid Program, this is important information that could affect your
decision to receive benefits from Medicaid.

Pursuant to State and Federal law, the State of Nevada administers a Medicaid Estate Recovery Program whereby correctly paid Medicaid assistance
is recovered from the undivided estate of the person who received Medicaid benefits. Medicaid recipients aged 55 or older and certain inpatients in
nursing facilities or institutions are affected by this program. When those individuals pass away, Medicaid requires that the undivided estates of those
individuals pay back any benefits paid by Medicaid.

“Undivided estate” is defined broadly in Nevada. It includes all real and personal property and other assets in or to which an individual had any interest
or legal title at the time of death. This includes assets conveyed to someone else through joint tenancy, life estate, living trust, annuity, homestead or
other arrangement. A Medicaid claim cannot be defeated by a homestead exemption or by the operation of bankruptcy or insolvency law.

Certain individuals are protected from Medicaid recovery. Medicaid cannot recover if the Medicaid recipient has a surviving spouse, a child under the age
of 21 or a blind and/or disabled child of any age. If Medicaid is prevented from recovering because of a surviving spouse, blind or disabled child or a child
under the age of 21, Medicaid may place a lien on the deceased recipient’s interest in real and/or personal property.

However, Medicaid must release the lien if the spouse, blind or disabled child or child under the age of 21 sells the property to a bona fide purchaser for
fair market value. If the exempted individual chooses to refinance the property, Medicaid will subordinate its lien.

In addition, certain income, resources and property of American Indians and Alaska Natives are exempt from Medicaid estate recovery. Please
reference Chapter 800 in the Medicaid Operations Manual at dhcfp.nv.gov for a detailed explanation of the property exempt from recovery for these
groups.

The above language refers to benefits that are correctly paid to eligible Medicaid recipients. When benefits are paid to persons who are not otherwise
eligible, those benefits are considered as incorrectly paid. Medicaid may recover incorrectly paid benefits immediately upon discovery and without the
restrictions that apply to correctly paid benefits.

Medicaid recovery may be waived, compromised or delayed if it would cause undue hardship for the heirs. Heirs may submit a hardship waiver request
at the time of Medicaid recovery. The denial of a hardship waiver or compromise may be appealed through the appropriate legal system. Medicaid will
provide hardship waiver application information to the known heirs at the time of recovery.

Please share this form with all family members and potential heirs.

If you have questions or need additional clarification, please contact the Medicaid Estate Recovery Program at (775) 687-8414, email mer@dhcfp.nv.gov
or visit its website at dhcfp.nv.gov under “Programs.”

I have read and understand the information on Medicaid Estate Recovery Notification of Program Operation. Initials D M K

Important Information
If you are applying for TANF and SNAP with this application and TANF benefits are approved, any adjustment to your SNAP benefits will be made at
the same time. With this application, you waive your right to 13 days advance notice of any decrease in your SNAP benefits. TANF benefits less than
$10.00 will result in no cash payment and will not affect the SNAP benefit.

The DWSS may send requests for information or appointment letters to the mailing address you provide on this application. If you do not respond to the
requests by the due date, your benefits may be denied or terminated.

As part of the application process, we may need to retrieve your information from the Internal Revenue Service (IRS), Social Security, the Department
of Homeland Security, and/or a consumer reporting agency. We will verify this information through computer matching programs, including the
Income and Earnings Verification System (IEVS). This information will also be used to monitor compliance with program regulations and for program
management.

Information provided by the applicant, beneficiary, or authorized representative in connection with this application will be subject to verification
by Federal, State or local officials to determine if the information is factual. If the information is determined to be incorrect, SNAP benefits may
be denied and/or terminated and the applicant may be subject to criminal prosecution for knowingly providing false information.

I have read and understand the Important Information listed above. Initials D M K

Your Rights to a Hearing: Cash Assistance Food Assistance Health Coverage

You can request a conference or a hearing if you disagree with our decision, or think we have not acted timely on your application. A written request
must be submitted within 90 days of the date of the notice, which will have more information about this process. If you need help, you can have
someone else act on your behalf, but written permission must be received by the DWSS before the conference/hearing.

For SNAP benefits you can ask for a hearing in person or by phone.
If you disagree with the hearing decision, you can appeal your case to your local District Court of the State of Nevada.

I have read and understand my rights to a hearing. Initials D M K

Parental Financial Obligation - Health Coverage

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.

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 I have read and understand the information on Parental Financial Obligation. Initials D M K

Health Plan Selection

Families who live in urban Washoe County or urban Clark County are covered by a managed care organization (MCO). You are being asked to choose
one of the following health plans. If you do not indicate a health plan preference on your application, we will choose a plan for you. Your choice of health
plan does not guarantee acceptance into the Nevada Medicaid or Nevada Check Up program. We might not honor your choice of plans if you or any family
members have been enrolled in one of our current managed care organizations. Once enrolled, families will receive a member handbook explaining the
health plan benefits and can contact the numbers below for information regarding the health plans.

Molina Healthcare SilverSummit Healthplan

1-833-685-2109 1 (844) 366-2880
meetmolina.com/nv-medicaid Silversummithealthplan.com

Anthem Blue Cross and Blue Shield Healthcare Solutions Health Plan of Nevada
1 (844) 396-2329 1 (800) 962-8074
mss.anthem.com/nevada-medicaid/home.html myHPNmedicaid.com

NOTE: If you do not choose a health plan preference, we will choose a plan for you.

For families living in the fee-for-service benefit area, services may be obtained from any Nevada Medicaid provider. If you need assistance in locating
a provider, please call your local Medicaid district office:

Carson City Reno Las Vegas Elko

(775) 684-3651 (775) 687-1900 (702) 668-4200 (775) 753-1191

Please choose a health plan.

How did you hear about this program?

Privacy Policy: Health Coverage

We keep your information private as required by law. Your answers on this application will only be used to determine eligibility for health coverage or
help paying for coverage. Nevada Health Link, the Division of Welfare and Supportive Services and the Department of Health and Human Services will
check your eligibility using our electronic databases and the databases of other federal agencies. If the information does not match, we may ask you to
send us proof. We won't ask any questions about your medical history. Household members who don't want coverage won't be asked questions about
citizenship or immigration status.

The DWSS needs this information to check your eligibility for coverage and help paying for coverage if you want it and to provide you the best service
possible. The DWSS may also check your information at a later time to make sure your information is up to date. The DWSS will notify you if we find
out that something has changed.

My information will be used and retrieved from data sources for this application. I have consent for all people I will list on the application that allows their
information to be retrieved and used from the above-mentioned data sources.

I have read and understand the information on the Privacy Policy. Initials D M K

Important Child Support Information: Cash Assistance and Health Coverage

By signing this application and by receiving TANF and/or Medicaid benefits, you agree to assign your child support rights to the State of Nevada Division of
Welfare and Supportive Services (DWSS). This is a condition of eligibility for your household to receive TANF benefits and the parents or adult caretakers
to receive Medicaid. If you are receiving TANF, any court ordered or stipulated child support paid directly to you are required by law to be surrendered
immediately to the DWSS or Child Support Enforcement (CSE). By signing this application, you are authorizing the DWSS to transfer all or part of the
support collected each month to pay back the TANF benefits your household received.

When applying for TANF and/or Medicaid benefits, the law requires you to cooperate with CSE to establish paternity to get child support and medical
support owed to you and any children for which you are applying. Good cause for not cooperating in pursuing child support or paternity may be allowed
if you think that cooperating to collect support will harm you or your children. If you do not cooperate with CSE and good cause was not established, your
household will be ineligible for TANF and Medicaid eligibility could be affected. If TANF is terminated and child support is collected, any portion due to
you will be made as a direct deposit onto a Nevada Debit Card or into your bank account. A Nevada Debit Card will be issued to you unless you request
payments by direct deposit into your bank account. Visit https://dwss.nv.gov for more information.

You are responsible for repayment of child support amounts received in error, including child support payments from an IRS tax refund which are adjusted
by the IRS. If you fail to enter into a repayment agreement with the CSE program, money collected on your behalf by the CSE program may be withheld for
repayment and the outstanding balance may be reported to a collection agency. The DWSS may charge a $25.00 fee for child support services provided
to clients who have never received public assistance.

I have read and understand the information on pursuing Child Support. Initials D M K

INFORMATION NEEDED TO PROCESS YOUR APPLICATION.

Attaching proof of the household's income (e.g. paystubs, bank statements, employer letter) to this application may help us determine your eligibility faster.

We may need other proof, such as verification of resources or expenses to process your application, but we will ask for this only if we need it.

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21
IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW, WOULD YOU LIKE TO REGISTER TO VOTE? Your decision will not affect
your level of service.

The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this location. If you select "Yes through mail", then
a voter registration packet will be sent to you through USPS. If you select "Yes through online registration", after your application has been submitted,
you will be provided with instructions on how to complete your voter registration online.

Yes through online

Yes through mail I decline to answer
registration

If you select "I decline to answer", then you will be considered to have decided not to register to vote at this time.

IMPORTANT NOTICE : Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance you will be provided by this
agency.

DAJAH MICHELLE KING 09/05/2022

Your Signature Date

CONFIDENTIALITY : Whether you decide to register to vote or not, your decision will remain confidential.

IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or your right to choose your own political party
or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89701.

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 Release of Information: Cash Assistance Food Assistance Health Coverage
I hereby authorize and consent to the release of all information concerning me 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 Medical 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.

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 information from liability, if any, resulting from the disclosure of the required information.

I have read and understand the information on Release of Information. Initials D M K

SUBMIT YOUR APPLICATION

If I am under age 18 and applying for TANF cash assistance, I must also have the signature of a responsible adult 18 or older.

I agree to notify the State of Nevada Division of Welfare and Supportive Services of any changes in my household circumstances that may affect my
benefits.

Failure to report changes may cause an overpayment that I would be responsible to pay back and could even be prosecuted by a court of law.

I swear I have honestly reported the citizenship of myself and anyone I am applying for.

I certify under penalty of perjury, my answers are true, correct and complete to the best of my knowledge and ability. Initials: D M K

By checking this box I acknowledge I am signing this application electronically. Initials D M K

DAJAH MICHELLE KING 09/05/2022

Client Signature Date

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