Form 2796-EM "Spousal Housing, Income and Resource Questionnaire" - Nevada

What Is Form 2796-EM?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 2796-EM by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form 2796-EM "Spousal Housing, Income and Resource Questionnaire" - Nevada

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STATE OF NEVADA
RICHARD WHITLEY, MS
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Director
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
STEVE H. FISHER
Administrator
STEVE SISOLAK
Governor
TANF
MEDICAID
SNAP
Date:
Case Name:
Case ID:
SPOUSAL HOUSING, INCOME AND RESOURCE QUESTIONNAIRE
Due to mandated spousal impoverishment provisions in the Medicare Catastrophic Coverage Act, portions of your community income and
resources must be made available for the benefit of your spouse. Please complete the following information concerning your spouse and
provide verification of income, resources and housing expenses by
. FAILURE TO PROVIDE THIS
INFORMATION MAY CAUSE INELIGIBILITY FOR MEDICAID COVERAGE.
Spouse's Name:
Social Security No.:
Address:
Spousal Income (Monthly)
Source
Amount
Spousal Expenses (Monthly) for Rent or Mortgage. Include mortgage principal and interest, taxes and insurance.
Type
Amount
Does your spouse live in the same residence as a minor dependent or child, dependent parents or dependent siblings?
(Claimed as dependents for Federal Income Tax purposes)
YES
NO
If YES, please list their name(s) and relationship to you or your spouse. What is their monthly income and source(s)?
Name
Relationship
Income Amount
Source
Check the box for each item below that your spouse owns or jointly owns with someone else:
2796 - EM (231.0.0)
Page 1 of 2
STATE OF NEVADA
RICHARD WHITLEY, MS
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Director
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
STEVE H. FISHER
Administrator
STEVE SISOLAK
Governor
TANF
MEDICAID
SNAP
Date:
Case Name:
Case ID:
SPOUSAL HOUSING, INCOME AND RESOURCE QUESTIONNAIRE
Due to mandated spousal impoverishment provisions in the Medicare Catastrophic Coverage Act, portions of your community income and
resources must be made available for the benefit of your spouse. Please complete the following information concerning your spouse and
provide verification of income, resources and housing expenses by
. FAILURE TO PROVIDE THIS
INFORMATION MAY CAUSE INELIGIBILITY FOR MEDICAID COVERAGE.
Spouse's Name:
Social Security No.:
Address:
Spousal Income (Monthly)
Source
Amount
Spousal Expenses (Monthly) for Rent or Mortgage. Include mortgage principal and interest, taxes and insurance.
Type
Amount
Does your spouse live in the same residence as a minor dependent or child, dependent parents or dependent siblings?
(Claimed as dependents for Federal Income Tax purposes)
YES
NO
If YES, please list their name(s) and relationship to you or your spouse. What is their monthly income and source(s)?
Name
Relationship
Income Amount
Source
Check the box for each item below that your spouse owns or jointly owns with someone else:
2796 - EM (231.0.0)
Page 1 of 2
a. Life Insurance ........................................................................................................................................
YES
NO
b. Funds Set Aside for Burial .....................................................................................................................
YES
NO
c. Savings (Time) Certificates
...................................................................................................................
YES
NO
d. Individual Retirement Account
..............................................................................................................
YES
NO
e. Stocks or Bonds
....................................................................................................................................
YES
NO
f. Banking/Credit Union Accounts
.............................................................................................................
YES
NO
g. Safe Deposit Box
...................................................................................................................................
YES
NO
h. Cash on Hand
........................................................................................................................................
YES
NO
i. Livestock
................................................................................................................................................
YES
NO
j. Machinery or Equipment
........................................................................................................................
YES
NO
k. Real Property (located anywhere) .........................................................................................................
YES
NO
l. Vehicles (all kinds)
.................................................................................................................................
YES
NO
m. Other (specify)
YES
NO
/
/
Client Signature
Print Name
Date
Telephone Number
2796 - EM (231.0.0)
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