Clark County Social Service

Assistance Application
Customer Service Call Center: (702) 455-4270

This application must be filled out completely, you must also sign the Certification and Release
of Information, Behavioral Contract and Reimbursement Agreement Forms which are included in
this packet.

ALL OFFICES ARE OPEN MONDAY THROUGH FRIDAY 7:30 AM TO 5:30 PM

Office Location

Pinto 1600 Pinto Lane, Las Vegas, NV 89106

2432 N. Martin Luther King Boulevard,

Community Resource Center North Las Vegas, NV 89032

3885 South Maryland Parkway,

Cambridge Annex Las Vegas, NV 89119
1291 Galleria Dr, Suite 170,
Henderson Henderson, NV 89014

1600 Pinto Lane, Las Vegas NV 89106

Senior Services
For more information please call (702) 455-8687

General Information

• Clark County Social Service most commonly provides assistance for rent, utilities, and transportation.

• Your application will be assigned to a Social Service Worker who will contact you to schedule an
interview.

• On your scheduled interview date and time, your eligibility for assistance will be determined. You will
need to provide all documents and verifications requested during the interview.

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 Clark County Social Service
Assistance Application
Phone: (702) 455-4270
Please complete this form to the best of your ability and print as clearly as
possible. Please ensure that you have included contact information.

1. Household information: Please provide the following information for all immediate family
members, significant others (Only if you have a child or children in common), and U.S. citizen
sponsors.
Street Address: Phone:
City, State, Zip: Email: _____________________

Male/ Date of Place of Birth Marital Social Security Citizen

Relationship Name Y/N? Ethnicity
Female Birth (City/State) Status Number

SELF

2. Please (√) check what type of assistance for which you are applying:

Financial: Transportation Other:

Rent/Mortgage 
Utilities 
Homeowner fees 
Real estate taxes 

3. Has anyone in your household ever served in the military? Yes  No 

If yes, please complete additional information below:
Branch:
Year entered military service:
Year separated from military service:
Discharge status:
Did you serve in a theater of operations? Yes  No 

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 If yes, name of theater of operation
4. Has anyone in your household received a lump sum of money in the
past thirty-six (36) months? Yes  No 
5. Has anyone sold, traded, pawned, or given away: money,
vehicles, property, other resources, or closed any bank accounts
thirty-six (36) months? Yes  No 
6. Please (√) check all programs listed below that you have applied for or are now receiving.
If you are getting the benefit, indicate how much you are receiving.

Social Security Benefits $ Temporary Assistance for Needy Families (TANF) $

Supplemental Security Income $ Food Stamps $
Retirement Pension $ Child or Spousal Support $
Veteran’s Administration (VA) $ Nevada Medicaid (CHAP, MAABD, QMB, SLMB) $
Unemployment Benefits $ $
Lawsuit Pending (Attorney: )
Workman’s Compensation $ Medical Coverage (Insurance, Medicare, HMO) $
Wages/Tips from Employment $ Other:
Gross annual income $

7. Are you pending any of the above programs? Yes  No 

If yes, which programs?
8. Have you been cut off any of the above programs? Yes  No 
If yes, which programs? When?

9. What is your total monthly household income?

10. What is your current employment status?
How long have you been employed?
11. Where have you worked for the last three (3) years?
(If you have not worked in the last three (3) years, list your last employer)

Begin date: End date: Employer’s Name:

Pay Rate: Occupation: Address:

Begin date: End date: Employer’s Name:

Pay Rate: Occupation: Address:

Begin date: End date: Employer’s Name:

Pay Rate: Occupation: Address:

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12. Where has your spouse worked for the last three (3) years?
(If your spouse has not worked in the last three (3) years, list his/her last employer)

Begin date: End date: Employer’s Name:

Pay Rate: Occupation: Address:

Begin date: End date: Employer’s Name:

Pay Rate: Occupation: Address:

Begin date: End date: Employer’s Name:

Pay Rate: Occupation: Address:

13. List all emergency contacts (parents, siblings, adult children, friends, etc.):

Name: Relationship: Phone:

Address: City, State, Zip:

Name: Relationship: Phone:

Address: City, State, Zip:

Name: Relationship: Phone:

Address: City, State, Zip:

14. Do you or does anyone in your household have any of the following resources?

 Savings Account  Checking Account

 Credit Union Account  Burial Funds
 Savings Bonds  Life Insurance Policies
 Vehicle(s)  Cash on Hand
 Stocks/Bonds  Trust Funds
 Individual Retirement Accounts (IRA)  Keogh Accounts (401k)
 Certificate of Deposit (CD)  Christmas Club Account
 Individual Indian Money Account (IIMM)  Other Account Type
 Other houses, land, or buildings  Promissory Notes or Contracts
 Life Estates / Life Leases  Mining Claims
 Land / Mineral Rights  Safe Deposit Boxes
 Business Checking Account  Business Equipment / Inventory
 Livestock  Other:
None of the above. (No one in the household has any of the above listed resources) initials:

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 Department of Social Service
1600 Pinto Lane • Las Vegas NV 89106-4309
(702) 455-4270 • Fax (702) 455-5950

Jamie Sorenson, Director

Pamela Kowalski, Deputy Director, Randy Reinoso, Deputy Director• Teresa Etcheberry Deputy Director

Certification and Release of Information

To the best of my knowledge, and under the penalties of perjury, I declare that all information provided
by me is true and correct. I will not sell, trade, willfully misuse or destroy any supplies / services given to
me. I will notify Clark County Social Service (CCSS) whenever there is any change in my circumstances
that might affect my eligibility for assistance.

I am aware that if I am denied assistance, I can appeal the decision. I am also aware that if I do not
provide all required documentation within 30 days of submitting this application, my application will be
withdrawn.

I hereby authorize CCSS to make any investigation concerning me or other members of my household /
service unit which is necessary to determine eligibility for any benefits I have or will receive under
programs administered by CCSS.

I hereby authorize and consent to the release of any and all information concerning me and my
household/service unit members to CCSS by the holder of the information, regardless of the manner or form
held, including, without limitation, information considered to be confidential by law or otherwise. I also
authorize CCSS to give any other governmental agency (local, state, or federal) information necessary to
determine my/our eligibility for assistance from either CCSS or the other governmental agency. I hereby
release the holder of such information from liability, if any, resulting from the disclosure of the required
information. A REPRODUCED COPY OF THIS AUTHORIZATION LEGALLY CONSTITUTES AN ORIGINAL COPY.

Signature (Head of Household) Date Signature (Spouse) Date

WITNESS: (Use if any applicant cannot read, write, and / or is blind).

I, , have witnessed that the above Certification and Release of Information

Statement was read to the applicant and have witnessed the signature(s).

Signature: Date: Address:

City, State, Zip:

BOARD OF COUNTY COMMISSIONERS

JAMES B. GIBSON Chair, JUSTIN JONES Vice Chair
MARILYN KIRKPATRICK • MICHAEL NAFT • ROSS MILLER •
WILLIAM MCCURDY II • TICK SEGERBLOM
KEVIN SCHILLER, County Manager

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 Department of Social Service
1600 Pinto Lane • Las Vegas NV 89106-4309
(702) 455-4270 • Fax (702) 455-5950

Jamie Sorenson, Director

Pamela Kowalski, Deputy Director, Randy Reinoso, Deputy Director• Teresa Etcheberry Deputy Director

Date: Notice Nbr:

Claim No:
Case No:
D.O.B.:
SSN No:

REIMBURSEMENT AGREEMENT

FOR AND IN CONSIDERATION OF all Services rendered or to be rendered to:

Client____________________________________________________________________, CCSS ID
________________________, by the CLARK COUNTY DEPARTMENT OF SOCIAL SERVICE, I
__________________________________________________________ promise to reimburse said
CLARK COUNTY the TOTAL charges incurred for all services received, should I acquire sufficient
financial ability to do so, from sources such as:

Settlement from a Lawsuit Receipt of Disability Benefits

Receipt of Unemployment Benefits Insurance Claim
Other Lump Sum Payments (e.g. Gambling Winnings, Inheritances, Lottery Winnings, etc.)

NOTE: This is not an all inclusive list and, regardless of the actual source of the funds, I promise to
reimburse Clark County Social Service. Reimbursement is normally not sought from wages,
except in the case of documented fraud.

_______________________________ ________________________________
Witness Signature Signature of Responsible Party

_______________________________ ________________________________
Witness Printed Name Printed Name of Responsible Party

________________________________
Address

________________________________
City State Zip

BOARD OF COUNTY COMMISSIONERS

JAMES B. GIBSON Chair, JUSTIN JONES Vice Chair
MARILYN KIRKPATRICK • MICHAEL NAFT • ROSS MILLER •
WILLIAM MCCURDY II • TICK SEGERBLOM
KEVIN SCHILLER, County Manager
 Department of Social Service
1600 Pinto Lane • Las Vegas NV 89106-4309
(702) 455-4270 • Fax (702) 455-5950

Jamie Sorenson, Director

Pamela Kowalski, Deputy Director, Randy Reinoso, Deputy Director• Teresa Etcheberry Deputy Director

Behavioral Contract

Clark County Social Service (CCSS) will strive to provide all services for which you may be eligible in an
atmosphere that is both safe and comfortable for staff and all customers.

The following “Behavioral Contract” is an agreement by which you must abide in order for staff to assist
you in qualifying for benefits.

Clark County Social Service employees will:

-Make every effort to address your needs and eligibility for CCSS
programs.
-Provide respectful and courteous service.
-Act in a professional manner.
-Abide by the policies and regulations of assistance programs offered.
Every Customer will:
-Treat staff with courtesy and respect.
-Speak in a moderate toned voice at all times.
-Make no derogatory, discriminatory or sexually inappropriate statements.
-Make no threats of violence, nor act in a violent manner towards staff.
-Refrain from consuming alcoholic beverages or illicit drugs immediately before and/or during a visit
to any CCSS office.
-Abide by the policies and regulations of the assistance programs for which you are applying.
-Maintain appropriate behavior at all times in CCSS lobbies/waiting rooms, an individual worker’s office or
client’s residence.

(See next page for Client Sanctions & Signatures)

BOARD OF COUNTY COMMISSIONERS

JAMES B. GIBSON Chair, JUSTIN JONES Vice Chair
MARILYN KIRKPATRICK • MICHAEL NAFT • ROSS MILLER •
WILLIAM MCCURDY II • TICK SEGERBLOM
KEVIN SCHILLER, County Manager
 Department of Social Service
1600 Pinto Lane • Las Vegas NV 89106-4309
(702) 455-4270 • Fax (702) 455-5950

Jamie Sorenson, Director

Margaret LeBlanc, Deputy Director, Randy Reinoso, Deputy Director• Teresa Etcheberry Deputy Director

Sanctions

F ailure to abide by the behavioral requirements could result in services being denied. You may also be
banned from all CCSS offices until such time you are able to conduct yourself in an appropriate manner.

Notice of Sanctions—given to every customer who begins to exhibit loud, rude or hostile behavior and to
applicants who become un-cooperative with workers who are trying to assist them. After receiving copy of
this contract, client may be asked to leave the office and return another day.

30 Day Sanction—imposed upon customers who act in a hostile manner and security guards are called to
escort them out of a Social Service office.

60 Day Sanction—imposed upon customers who act in a violent manner and require the police to be
called to remove them from Clark County Social Service offices.

Permanent Sanction—imposed on customers who threaten employees or exhibit violent/aggressive

behavior such as throwing things, grabbing papers from an employee, etc. If permanently banned from
Social Service offices, you will be required to conduct all business with the agency by mail.

Clients can request and submit complaint forms through front desk staff, an office lead, supervisor, or
by speaking with the CCSS Ombudsman regarding concerns about the service they receive. Complaint
forms are also available on the internet by searching “Clark County Ombudsman” and following the
links to the complaint form for Clark County Social Service. Complaint forms can also be faxed to
the Ombudsman at
(702) 868-2544 or discussed by telephone at (702) 455-1046.

By signing this contract, you are acknowledging that you have been informed of and you understand what is and is
not
acceptable behavior when applying for services at any CCSS office. You are also aware of the possible
consequences of not abiding
by this contract.
Client Signature: Date:

CCSS Staff: __________________________________ Title: ____________________ Date:_____________

Customer may receive a copy for their records.

BOARD OF COUNTY COMMISSIONERS

JAMES B. GIBSON Chair, JUSTIN JONES Vice Chair
MARILYN KIRKPATRICK • MICHAEL NAFT • ROSS MILLER •
WILLIAM MCCURDY II • TICK SEGERBLOM
KEVIN SCHILLER, County Manager