2488-EG - Housing/Rent Authorization Form (TANF/Medicaid/SNAP) - Nevada

Sep 19, 2026

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Authorization and landlord/manager information form for Nevada Department of Human Services, Division of Social Services. It collects household composition and rent/utility details needed to determine TANF, Medicaid, and SNAP eligibility, including client identification, resident names, move-in dates, forwarding address, and questions about government-provided housing or rent portions under HUD programs. The form also requests monthly rent or market value, payment status, payment method, utility reimbursement amounts, heating/cooling and appliance or furniture rental fees, and whether outside parties pay rent. Signature and contact fields support confidentiality and accountability.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Authorization and Signatures

Client Signature and Authorization to Release Information

Rent/Household Composition Details

Household Members and Move Dates

Government Housing Programs and Review Dates

Rent Payment Terms, Utilities, and Fees

Joe Lombardo Governor Laura Rich Director DEPARTMENT OF HUMAN SERVICES DIVISION OF SOCIAL SERVICES Helping people. It’s who we are and what we do. Robert H.Thompson Administrator TANF MEDICAID SNAP Date: Case Name: Case ID: | AUTHORIZATION: I authorize you to release to
the Division of Social Services information.
the requested | | --- | | Client Signature Date | RENT/HOUSEHOLD COMPOSITION The following information is necessary to complete you case and must be IN our office on or before undefined . FAILURE TO PROVIDE THIS INFORMATION MAY CAUSE TANFAND SNAP INELIGIBILITY. TO BE COMPLETED BY: Landlord or manager only Friend or neighbor UNDER NO CIRCUMSTANCES CAN ANYONE LIVING IN THE HOME OR A RELATIVE COMPLETE THIS FORM. Please provide the information below and return to the above address. Your cooperation will help ensure integrity and maintain accountability in the administration of public funds in Nevada. The information provided us will be used only in conjunction with the official duties of this department and will be considered confidential. An immediate response would be appreciated. If our identifying information (name and address) does not agree with your records please indicate the change. RE: (Name) (Street/Residence Address) 1. List the full names of EVERY person (INCLUDING the above person) living at the above address: 2. When did begin living at this address? 3. If no longer living at this address, date moved Forwarding address Street City State Zip 2488-EG (278 .0.0) Page 1 of 2 4. DOES A GOVERNMENTAL ENTITY PROVIDE HOUSING OR PAY A PORTION OF THE ABOVE CLIENT'S RENT? YES NO IF YES, WHO? Redetermination/Review Date Under what program? HUD Conventional Public Housing Section 8 HUD Indian Housing: Mutual Help OR Rental Assistance FmHA Rental Assistance Other 5. Total monthly rent or estimated market value of rent $ , pays $ Client's Name Amount of utility reimbursement payment $ Date payment started 6. Is the rent paid to date? YES NO Date paid First Month's Rent $ 7. How is the rent paid (cash, personal check, money order, paycheck, etc.)? 8. List all responsible parties to the terms of the lease. 9. Does a person outside the household pay any portion of the rent? YES NO If YES, specify who: Amount $ 10. Does rent include heating and cooling? YES NO Amount $ Appliances/furniture rental fee? YES NO Amount $ 11. Does anyone in the household work in exchange for rent? YES NO If YES, who: Date started Amount $ 12. Please verify the amount of utility allowance the client receives monthly $ Date payment started Is amount paid to client? YES NO Signature Print Name Title/Relationship Date Telephone Number Address Agency Name Apartment Complex 2488-EG (278 .0.0) Page 2 of 2

FAQs

What information must be completed to avoid TANF and SNAP ineligibility?

The form states the needed information must be in the office on or before the specified deadline. It warns that failure to provide the information may cause TANF and SNAP ineligibility.

Who is allowed to complete the form?

The form indicates it is to be completed by a landlord or manager only, or in the case of a limitation, by a friend or neighbor as allowed by the form wording.

What rent-related items are requested on the form?

It requests total monthly rent or estimated market value, whether government entities provide housing or pay a portion of the rent, rent payment status and date, payment method, utility reimbursement payment and start date, and whether heating/cooling and appliance or furniture rental fees are included.

Sep 19, 2026

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