DIVISION OF ITELFARE AND SUPPORTTVE SER\ICESChild Care and Development Program

FILL IN ALL BI.ANKS FOR EVERYONE WHO CURRENTLY LN'ES IN THE HOME WITH YOU,WHETHER YOU CONSIDER THEM HOUSEHOLD MEMBERS OR NOT. If vr md atld;tiora/ s1ao,2ha.x nc a renula rlndlio, a.

'.l.tdk ?t a alttr?cr.

Ethnicitla H = Hispanic/Latino N = Non-Hispanic/latinoRace: A-Asian; B-Black or African American; I-American Indian ot Alaska Native; N-Native Hawaiian or Pacific lslander; W-WhiteMarital Status: S-Singlc; M-Married; N-Scparatcd; D-Divorccd; V-Widowed

ADULTS:

Lq.l Nme

sD.t. ofBinh:

Countryof Binh Social Se.u.ity Nmrber Erhnicirv

Marit.l

Sclf

CHILDREN nder the of1

Please Answer the F tions About Your Household:

2

s

Binh of Binh

USCnizenY/N Social Security Numb€r Erhnicity

child

D Ycs

DN"E Yes

EN"E YcstrNoE Y.sExntr YcsDN"

Ciry Zi?

Mai}ng Address Z,PCity

Phonc ! Homc E) \\b* E ccrr Phonc f] Homc E vb* E C.U Il-Marl Addres

1. IB your Family Homeless (ack a 6xed, regular, and adequate nighttirne residence)?

t minor patent) in your household unable to wotk and/ot atrend a training p.ogram? ! Ves ! No

lves lNo

fl Yee ! No

IfYes, N Reason

Reason:

Active Dutv or Reserve?

Current IEP or IFSP for child? _

4. Do any ofthe children in the household have special needs?

IfYes, Please Explain

2. Is any household member in rhe Military?

Current IEP or IFSP for child?

lyes !NoCurrent IEP or IFSP fr.rr child?

If Yes, Name

3, Is any adulr (o

If Yes, NameNameName

215l wC (r0- 15)

PLEASE ENTER RACE/ETHNICITY/MARITAL STATUS CODES FOR EACH HOUSEHOLD MEMBER INTHE BOXES BELOW:

lll [--T---

I

f-[[---T---T--l-

5. Is any houeehold member, including a minor child, temporatily out of the home? ! Yee !NolfYes, Name: Reason: xoccted date of Return:

lYes !No

7. Has any household membet received TANF cash benelits? lves lNoIfYes, Namc:- lUhcn: \(".}rcrc:

8. Is anyone curently disqualifred from any DWSS progtam for an intentional progam violation (IPV)? ! Ves ! NoIf Ycs. Name:- Program: Start Datc:

9. Does your household have assets with a valuc over one million dollars ($1,000,000)? lvea I NolfYes, Name Tlpe of Asset:

10. Do you expect any other changes in the next six (6) months? flves ! NoIfYes, Please Explain:

11. Is anyone paying all ot patt ofyour expenses (rent, utitties, child care, etc.) fot you? ! ve" ! NoIfYes, who: Amount paid: How Often

Are you expected to tepay this money?

12. Are both parente ofthe children living in the home?

UNa,PhanCon btt /b. Lrfol",ation Bdo, Abont th Cbild(nr)t Motbcr a /ot Fntb$ ttat doci flot li". t'ithfo't.

fl yeo fl no

I Yee !NoAttath Addinnat Paga, if Ntturary.

Name .nd A.ld.ess of P,rentnot residing in thc Household

Receive ChildSupport? How Often

Received throughwhich medium?

Eyes

Ex.

I wceklyI Bi-weekly

I Semi-monfilyI Monthly

! o-t.'s oncc! Coun Agreement

! Priutc AgrccmcotAddr*t.

Pltoat: ( )

! r'*

!x.! wee tlyI Bi-wcekly

E S€mi-montl'ly

I Mont]rly

E D.A.t of6€€! Coun fureemcnt! Private Agreemcnt

Addntt

Phone: ( )

L_.1 r es

EN.

! Wcckly

! Bi--eektyI semi-mondrly

! Monthly

E D.A.'s offcc! Coun Agreement

! Privrte AgreementPhone: ( )

INCOME/BENEFITS OTHER THAN EMPLOYMENT INCOME izanc rcoi*d itr tlte )0

E 01- TANFE 02- SNAP

! o3- Housing Assistrncc

! (X- Foster Care Palrnents

[ 05- Vctcmn's Bcnc6ts

! 06- Lump Sum Patrncnts

E 07- Militiry AloEnents

E ls urc! tc - r;psE 17 - Di\.idends

E 18 - Rovrlties

I lo - Interesr

E 20 - NinningsE 2l - Alimon!

! 22 - Supplcmcntal Security Incom. (SSD

E 23 - S.rci"l S.c"riq' DisabiJiq Benedts

E 24 - Social Sc.*ity Survivots Bencfits

I ZS - S"ciat Se.*ity n tirement Benefts

E 26- Pcnsions/Retircmcnt Tmsts

E 27 - Adoption subsidicsfl 28 - Mcdjc.id

!trD

E 0t! v'orkcr's Compcnsation

E 09 - Tempora4 Disability Insuraflce

[ 13 - Rai]road Rctircmcnt

[ 14 - Insurarcc Sctdcmcnts

10 - Educ*ior.l Assistaocc/Pcll Grants11 - Unemplo)m€ntI 2 - Cootriburions or lr.ns

How Ofren\vho Receives

rhe IncomeHow OftenIncomeTlpe #

Who Receivesthe Income

IncomeT11pc #

3 21sl-vc 0Grs)

6, Is any household member pregnant?If Yes. Neme:

-

Anticipeted Delivery Date:

-

Child's Name

i,'-kind a4nitie' a odd

TRAINING/EDUCATION: Il q of tlx attt ir rtx tn '.ha an 'tdnt! ?anni?dtirg in d taini,sfnsrz'r, or dte iq rcboot, pha!. .onpbk tbc [olbuir.q

CHII.D'S SCHOOL INFORMATION:

Child's Name Nrme of School School Schedule/School Track Cutrent Grade Level

CHILD CARE PROVIDER:

Child or Children's NamesP.ovider Name

Ad&ess and Phone Number

Addml

Phonc: ( )

.4ddrus.

Pbore: ( )

4

HouseholdMember

Srefl Date/End Detc

Employer NameAd&ess md Telephone Number

AverageWeeklyHouIs

Rate ofPav

How OftenPaid Schcdulc/Shift

E wcckly

E Bi -e€kl).

! Semi-monthly

! Mon$Jy

D Commission

tr! IlonEt',E t'"I sat

! s"nEr"cE v'ed

From:

To:

Addrut:

Pltom:

()! veckly

E Bi tr'eckrr

E Semi monthlr

I Monfi]y

! Commission

Schcdulcl

! v*"s! lr"n! r,eD w.dFrcm:

Em,EFi! Sat

E s,.

To:

A&lrut:

Plon:

()

StudertName

Training Site/School NemeAddrcaB and Phone

BeginningDate

EndDate

Pho*: ( )

Addnss:

Plmc: ( )

YOUR RIGHTS

2r5l,vc (r0- l5)

Schedule

Anyone who has been denied, terminated, or had bene{its reduced will receive a notice and instructions for requesting a hearing ifyou do not agtee with the action taken. You can request a hearing by writing your local child care office, Division of Welfare andSupponive Services @WSS) district office or administration office. You can also rcquest a hearing by signing and rctuming theNotice of Appeal you reccive. You must request a hearing within 90 days ofthc notice date or within 14 days if you want continuedbenefits while your hearing is pending a decision.

Ifyou request a hearing, 1'ou will be notified ofthe hearing datc, time and location in writing ten (10) days prior to the scheduledhcaring. You may be rcpreseoted at a confereoce/hearing by anlone whom you have given wtitten authorization. This.minenauthodzation must be given to the DWSS office before dre conference/hearing. Please conact us if you need information on legelservices that may be available to vou at no cost.

If you disagtee with 1'our hearing decision, you cao appea.l vour case to your local District Court of the State of Nevada.

AUTHORIZATION / RESPONSIBILITY

The Child Care and Developmcnt Progtam is funded by State and federal grants. Any information ptovided on this form can beinvestigated. Criminal prosccution aod other penalties may be applied to you and/or other adult members of your householdaccording to state and fcdcral law. If you make a false or mislcading starcment, misreprescnt, hide or withhold facts to get or keepchi.ld cale assisance, your benefits may be reduced/denied/terminated. Additionally, you ma)'not be etigible for future assistance,

and you are responsible to pay back all monies, sewices and benefits for which you were not entided. lnformation provided isstrictly confidential and is used only to determine eligibiliw fo! child care asslsrance.

Ry signing below, you authorize the Child Care and Dcvclopment Program and/or the Division of Welfare and Supportive Servicesto make any investigation conceming you or other membets of yout household or your children's legal/putative parent(s) that is

necessary to detennine eligibiliq' for cbild care assistance administered by the Child Care and Development Program.

By signiog below, you authorize the release of information about your household membe$ to the Child Care and DevelopmentProgram including, wage information, information made confidential by law or otherwise, and patient information privileged undcrNRS 49.225 or an)'other provision oflaw or othcrwisc. You release the holdcr of such information from liability, ifany, resultingfrom disclosure of the required information. A reproduced copy of this authorization legally constitutes an original copy.

By signing below, you acknowledge that you undcrstand the questions on this application and the penalty fot hidiog or giving false

information. In addition, you undentand that if you make a false or misleading statement, hide or withhold facts to get or keep

child care assistance, your benefits ma1'be reduced, denied, or terminated and you may be disqualiEed from progtam participation,criminally prosecuted, or otherwise penalized according to state and federal law.

In addition, by signing belou you con6m that the provider(s) listed above reflect thc choice made by you, the parent/cateaker, and

),ou agree to indemni$, and hold harmless the Sate of Nevada, the Child Carc and Development Proglam, their officets, agents,

board members and employees ftom all claims, litigetion, costs, expenses and liabilities arising out o( or in any way connected withthe providet chosen by you.

I certi$ under penalty ofperiury, my ansv/eta are true, corect and complete to the best of my knowledgc and ability.

Sign.turc orM.rk of Applic.nr (Parcnt/Guardian)

Date Signature or Mark ofSpouse/SecondParenr/Guardian of Child(ren)

5 2l5l-'JsC 00'15)

Date

IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW,WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?

@lease checl one)

flYES ENoIfyou do not check either box, you will be coneideted to have decided not to registet to vote at this time.

The NATIONAL VOTER REGISTRATION ACT provides you u/ith the opporturdt,' to register to vote at this locatioo. Ifyou would like help in fiIling out a voter registration application fotm, we will help 1'ou. The decision whether to seek or accepthelp is yours. You ma1'fill out the application form in private.

IMPORTANT NOTICE: App\'ing to register or declining to rcgrster to vote r0(IILL NOT AFFECT the arnount of assistance

1'ou will be provided by this agency.

Signature Datc

CONFIDENTIAIJTY: r0?hether you dccide to register to vote or not, I'our decision will remain con6dential.

IF YOU BELIEVE SOMEONE, HAS INTERFERED with your right to register or to decline to register to vote, or your right tochoose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State,Capitol Complex, Carson Ciry, Nevada 89710.

5 215l-wc 00,15)

8OX 3 - llAfE Please write you. name exacfy as at appeaG on lhe Nevada driver'sllcense,lD card, o( SocialSecudty card rclerenced in Box 8. tf you do not have any olthese lorms of ldentilication. please see lhe lnslrucllons for Bor 8,

aOX 4 - tloilE ADDRESS Your home addr€ss is the street address assigned to thelocalion al which you actually reside, lf you reside at a localion that has not beenassigned a street address, a dsscriplion ol th€ location at which you actually r€sidemusl be provided.A PO. Box cannot be listed as a home address.

aOX a - DEI{TIECATIO REOUIBEfiEiITS Federal and slate law require you to provideyour NV driver's license or lW lD number It you do not have either, you must providethe last 4 digits ol your social security number (SSN). lf you do nol have any of theselhroo forms of identrfication, please conlact your County Clerk/Registrar after you havecompl€led and relumed this form.

AOX 11 - PAnTY REGISTRAnOI Mark your choice of a qualified party, "Nonpartisan'or "other" ll you malk "other,' you may print the name ol an unlisted political party.

ll you register with a minor politjcal party or as a nonpartisan, you will receive a non-panisan ballol for the Primary Election.

tr AGENCYtr FIELD REGISTRARO MAILO OTHER

CANCELLED

INACTIVE

PRECINGT

A0l la - ASSISTI G l TtlE C,l}tgPLEnO OF r|lls FOR If you are assisting aperson lo register to vote, you must complele 8ox 1 4. HILURE T0 D0 S0 lS A FELoNY

OEAOIII{ES FOR SUAMTNI{G APPIICATIO* By MaiF-+ostmarked by Saturday, 31 days before an Electron.* ln Person at DMV-by Saiurday,3l days betore an Election.* online..by Tuesday, 21 days before an Electon.* ln Person At County Clerks or Rogistrar's Offico-by Tuesday, 21 days

belore an Election (for Munlcipal Electlons, in person at City Clerk's).

t For SpeclayRecall Elections----contacl your County Clerk or Reglstrar

IQIICE You are urged lo return your application lo register to vote to lhe Coontyclerl/Regist ar in person or by mail, ll you choose to give your completed appllcatonlo anotier person to refum to the County Cle*,n€gBt ar on your behalf, and the person

lails to deliver the application lo the County Clerli/Regislrar, you will mt be registerodlo vote, Please retain the duplicate copy or receipt trom your application to reoister lo

USE BLACK INK - PLEASE PRINT CLEARLY WARNING: GIVING FALSE INFORMATION lS A FELONYAND INCLUDES A CIVIL PENALTY OF UP TO $2o,(xx).

I Are you a cilizEn ol th6 lJnltod Stat€s ol fun8rica?Wlllyou be 18 years of age or ovor on or before Aedjon Day?lf you chock€d "m" in responso to oathor of lhgs€ qusstioos, do nolcomplele thls foam.

NoNo

Check boxes thal apply and complete atems 3-14

I New Rsgistralion f l Party Affiliation Change

I Name Change I Address Change

3 Last Name (only) First Name (only) Middle Name (only) Jr. Sr. ll lll lV

4 Home StreetAddress {No P.O. Bo/Euslness Address. See lnstructions,) Api., City State Zip Code

Nlailinq Address----lf differenl lrom above. (PO. Box or ilailServrce Address) 6 Birth Date (M/D,"ra) 7 Place ol Birth (state or country)

NV Driveas License No./W lD Card No./Lasl4 of SSN I Telephone No. (opt) 10 E-mallAddress (opt.)

'IFarty Registration---check only on6 Box

E Democratic Party

E lndependent American Party

E Libertarian Party

L I Nonpartisan (no party atfaliation)

I I Republican Party

U Other Farty - Write ln Below

12 ''l swear or aflirm . I am a u.S. citizen . lwill be at least 18 years old by the date ol the next el€ciion. lwillhave continuously rosided in Nevada at least 30 days in my county and at l6ast 10 days in myprecirrt b6lor€ th6 n6xt €lection . The present address listed herein is my sol€ l6gal place ol rcsid€ncaand I daim no oth€r place as my legal residence . I am not laboring under any felony conviction o(other loss ol civll righls that would make it unlawlul tq me to vot€. ldeclare under penalty ol perjurylhat the toregoing is true and correct."

I SIGNATURE OFAPPLICANT (REOUIREO) T T DAT€ (BEOUIREq I

J-J-

13 Your name and residence address where you were lasl registered to vole, lName Used, Street, Apt. *, City, Stale & Zip Code ol Former Residence)

't4 lmporlanl! l, you are assisting a porson io rgSiaiorE voia androu-rei idd rogastrar appointod by a County Clorl/Reoistrar or an employ€€ of a vol€r

registraton agencl, you MUST complete the ,ollowing. Your signature is requireal. Failure to do so is a lelony

II|TERESTEo n AEI G A mLL WORXER? Please contact your local County Clerk orRegislrar's Offce. See Reverse.

L ] CHECK THIS BOX TO RECEIVE A SAMPLE BALLOT IN I.ARGER TYPE

VALIOATING AGENCY USE ONLY. DO NOTWRITE IN THE SHADED AREA BELOW.

I Delach Here I i I Detach Here I

NAiIE OF PERSON RETAININGTHIS APPLICATTON

(AOEIICY ST^MP OF NUE OFrNar APPUC^rrcff)

VOTER APPLICATION RECEIPT( P lea se R etain R ece ipt)

ll you do .roi r€coivg a Ar€lracla l@et Rogls',tonCard ln lhs mallx,lthln 10.lays. Ploaas call or vlsn

yoor Couhty El€ctioo OeParlrnanl.

PRINT NAME OF PERSON FETAINING FOFM

(Revised 7.2015) ,Nsrc k e,r

ELECTION OFFICIAL OR AGENCYContact lnlormation, Address, Tel6phone, Fax

APPLICATION NO. HAo,ro: <F

SECRETAFIY OF STATE BARBARA K. CEGAVSKESTATE OF N EVADA

VOTER REGISTRATION APPLICATION

Application No.

HA

APPucaTloN No. l{/ARECEIVED BY:

5

a