Property & Finances

a. General Information

Public Assistance. I receive federal and/or state public assistance benefits: Check this box if you get any government help listed below. Then check each kind you receive.

b. Health & Medical Support

Medicaid / Nevada Check Up Check this if you get Medicaid or Nevada Check Up health coverage. SNAP (food stamp assistance) Check this if you get SNAP food stamp benefits. TANF (temporary assistance for needy families) Check this if you get TANF cash help for families. Low-income energy assistance Check this if you get help paying your energy or utility bills. Child care subsidy / Child Care & Development Fund assistance Check this if you get help paying for child care. Public housing Check this if you live in public housing or get housing help. SSI (supplemental security income) Check this if you get SSI payments because of low income, age, or disability. Other federal and/or state public assistance: Check this if you get other government help not listed above. Other federal and/or state public assistance: Write the name of the other government help you receive. Low income. My household net income is equal to or below 150% of the federal poverty guidelines. Check this box if your household's take-home pay is at or under 150% of the federal poverty level. Then fill out the income tables below. In my household there are _____ adults (over 18) Enter how many people age 18 or older live in your home, including yourself. and _____ children (under 18) Enter how many kids under age 18 live in your home. for a total of _____ people. Add the number of adults and children together and write the total here. Employment (include tip/overtime) Enter your monthly pay from work after taxes, including tips and overtime. Unemployment Enter the amount of unemployment benefits you get each month after taxes. Retirement / Pension Enter your monthly retirement or pension payments after taxes. Social Security Enter how much you get from Social Security each month.

c. Child Support

Child Support Enter the child support you receive each month. YOUR TOTAL Add up all your monthly income amounts above and write the total here. My total income (your total from above): Copy your total monthly income from the table above. Adult's name: Write the full name of another adult who lives in your home. Adult's name: (net monthly income) Enter that adult's take-home pay each month after taxes. Adult's name: Write the full name of another adult who lives in your home. Adult's name: (net monthly income) Enter that adult's take-home pay each month after taxes. Adult's name: Write the full name of another adult who lives in your home. Adult's name: (net monthly income) Enter that adult's take-home pay each month after taxes. Adult's name: Write the full name of another adult who lives in your home. Adult's name: (net monthly income) Enter that adult's take-home pay each month after taxes. HOUSEHOLD TOTAL Add your income and all the other adults' income together for the household total. My basic expenses are more than my income. Check this box if what you pay for basic needs is more than you earn. Then fill in the income and expense tables below. Employment (include tip/overtime) Enter your monthly pay from work after taxes, including tips and overtime. Unemployment Enter the amount of unemployment benefits you get each month after taxes. Retirement / Pension Enter your monthly retirement or pension payments after taxes. Social Security Enter how much you get from Social Security each month. Child Support Enter the child support you receive each month. TOTAL Add up all your monthly income amounts above and write the total here. Rent / Mortgage Enter what you pay each month for rent or your home loan. Utilities (electric, gas, water, phone, other utilities) Enter your total monthly cost for electric, gas, water, phone, and other utilities. Food Enter how much you spend on food each month. Child care Enter what you pay each month for child care or daycare.

d. Health & Medical Support

Medical expenses (health insurance, co-pays, out of pocket expenses) Enter your monthly medical costs like health insurance, co-pays, and out-of-pocket expenses. Transportation (bus fare, car, gas, insurance) Enter your monthly cost for getting around, like bus fare, car payment, gas, and insurance. TOTAL Add up all your monthly expenses above and write the total here.