IMPORTANT NOTICE
How to Apply for the Energy Assistance Program (EAP)
Submit a completed application (to include the name, date of birth and Social
Security Numbers for EVERY PERSON who lives in your home) with the
following verification:
1. Proof of identity for the head of household (such as a driver’s license, government
issued I.D., school I.D., etc.) and;
2. Proof of citizenship or legal status if born outside of the United States and;
3. Provide a copy of most recent heating/cooling bills and;
4. When the utility bill is not in the applicant’s name, provide a written statement from
the person listed on the utility bill authorizing the applicant to apply, that includes
their address, phone number and signature and;
(07/24)
5. Proof of ALL income for EVERY PERSON in the household for at least the last
thirty (30) days.
Examples of types of income: Employment, child support, social security, Veterans
benefits, retirement, public assistance, utility reimbursements, unemployment
insurance, interest income, money from family and/or friends, or organizations,
educational scholarships and/or grants, etc.
Note: If the employed individual is working through an employment agency,
provide proof of the last 12 months of earned income.
6. If the household expenses exceed the household income, proof of how the household
is meeting their needs.
**FAILURE TO PROVIDE THIS INFORMATION MAY DELAY THE
PROCESSING OF YOUR APPLICATION. **
Applications are processed in the order in which they are received.
Applicants will receive a notice of decision once an eligibility determination has
been made.
(07/24)
Please mail or fax your application and verifications to:
Energy Assistance Program Energy Assistance Program
2527 N. Carson St., #260 3330 E. Flamingo Rd., #55
Carson City, NV 89706 Las Vegas, NV 89121
Fax: (775) 684-0740 Fax: (702) 486-1441
(07/24)
Division of Welfare and Supportive Services
ENERGY ASSISTANCE PROGRAM APPLICATION
The Energy Assistance Program (EAP) is designed to help eligible Nevada households with
their annual heating and electric costs.
INCOME REQUIREMENTS
The total gross monthly income of all household members may not exceed the amounts shown
in the chart below.
YOUR HOUSEHOLD’S GROSS MONTHLY INCOME MAY NOT EXCEED:
Persons in Home
1
2
3
4
Annual
Income
$22,590
$30,660
$38,730
$46,800
Monthly
Income
$1,882.50
$2,555.00
$3,227.50
$3,900.00
Persons in
Home
5
6
7
8
Annual
Income
$54,870
$62,940
$71,010
$79,080
Monthly
Income
$4,572.50
$5,245.00
$5,917.50
$6,590.00
(For families/households with more than 8 persons, add $8,070 to the annual income for each
additional person).
Households with a chronic or long-term illness, who pay out of pocket medical expenses and
whose gross income exceeds the income guidelines may have their countable income reduced
by verified qualifying expenses.
(Page A) 2824 – EL (07/24)
Does a household member have a chronic/long-term illness and pay out-of-pocket medical
expenses?
□Yes □ No
(If Yes, and your income exceeds the limits above, please submit verification of your out-of-
pocket medical expenses.)
BENEFITS
Eligible households receive an annual one-time-per-year benefit called a “fixed annual credit”
customarily paid directly to their energy provider(s). The benefit shows as a credit on the bill.
Minimum Payment – The minimum yearly payment for eligible households is $360.
WHEN TO APPLY
If your family is not currently on the program and you meet the income requirements, apply
NOW.
If you received an EAP benefit during the past 12 months, a notice will be mailed to you
when it is time to reapply for EAP.
(Page A) 2824 – EL (07/24)
WHAT DO I NEED?
Submit a completed application with the required verification. Suggested income verifications
are noted on the back of this page. To get answers to other questions, call:
Reno/Carson City (775) 684-0730
Las Vegas (702) 486-1404
Toll Free (800) 992-0900
Visit our website at: http://dwss.nv.gov for more information on the program
requirements.
You can find information about the Weatherization Assistance Program at:
http://housing.nv.gov/programs/Weatherization/
(Page A) 2824 – EL (07/23)
DOCUMENTATION EXAMPLES OF REQUIRED PROOF OF INCOME
All documentation sent with your application can be either originals or photocopies. If you are
unable to photocopy the originals, our office will copy the material and if requested we will send
it back after your case has been processed.
Earned Income: Includes income from employment, self-employment (see below), child care
services, house cleaning, and/or any service for which you are paid. Provide copies of check
stubs (if paid in cash, a statement from the person who paid you for a service) for at least the
last thirty (30) consecutive days. If paid weekly – 4 check stubs; paid bi-weekly or semi-monthly
– 2 check stubs. If you do not have check stubs, a signed and dated statement on letterhead from
your employer stating your gross income for the last thirty (30) days and how often you get paid,
is acceptable. If working through an employment agency or on-call provide proof of the last 12
months of income.
Self-Employment/Non-Profit Business Income: May include profit and loss statements
signed by the applicant detailing gross income and expenses (receipts must be provided for
deductions) during the last 12 months, a copy of the sales tax statement showing gross net
proceeds, financial statements, a loan application listing income and expenses for the last 12
months, or DWSS Form 2011 that includes receipts for allowable deductions. Allowable
deductions include: cost of goods sold, supplies and materials, advertising, accounting and legal
fees, wages paid to employees, office space rent/mortgage, telephone, utilities, transportation
costs necessary to produce income, etc.
Unearned Income: Includes income from the Social Security Administration, Veterans
(Page B) 2824 – EL (07/22)
Administration, pensions, disability, military service, unemployment, child support, alimony,
interest, dividends, regular insurance or annuity payments. If you are receiving Social Security,
SSI, Veterans Benefits, pensions, disability income, military income or unemployment:
provide copies of the benefit verification form or award letter for the current year showing any
cost of living raises. If you are receiving child support/alimony income: provide a copy of
divorce decree/separation/settlement agreement, or dated letter from the person paying the
support (to include name, address and phone number), or a copy of the last check/statement from
the child support enforcement agency. If you are receiving interest income/dividends: provide
12 months of bank account statements, certificates of deposit or other documentation that
contains details and is signed by the financial institution, or a broker’s quarterly statement
showing earnings.
Cash Contributions and/ or Recurring Gifts: If someone is helping you pay your expenses
or is giving you money: provide a signed statement from each person that includes their name,
address, phone number, if the assistance will continue, and the amount provided to you during
the last six months. Provide a signed and dated statement by the person providing the money
indicating the amount of support, how often it is paid, when the arrangement began, and whether
it is paid directly to a vendor or in cash to you. The statement must include the contributor’s
printed name, address(es), and phone number(s).
Student Income: Includes ALL scholarships and grants, e.g., Pell Grant, Federal Supplemental
Educational Opportunity Grant (FSEOG), Veterans Administration educational benefits, etc.
Please provide written confirmation of the amount of assistance, and the educational institution’s
written confirmation of the cost for the prior two (2) semesters and summer school (if applicable)
of the student’s tuition, fees, books and equipment. If benefits are paid directly to the student,
copies of the latest benefit checks or canceled checks or receipts for tuition, fees, books, and
equipment are acceptable.
(Page B) 2824 – EL (07/22)
Public Assistance Income: Includes but is not limited to TANF, county general assistance,
Clark County Social Services, or American Indian/Alaska Native General Assistance. Provide
a written statement from the public agency with the amount paid during the last month, or a copy
of the award letter or check.
PLEASE NOTE: 1099 and W-2 forms by themselves are not acceptable as proof of
income.
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
ENERGY ASSISTANCE PROGRAM
MAIL OR FAX YOUR APPLICATION TO ONE OF THE OFFICES LISTED BELOW
OR EMAIL YOUR APPLICATION TO: ENERGYASSISTANC[email protected].GOV
LAS VEGAS / NORTH LAS VEGAS OFFICE FOR ALL OTHER AREAS
3330 E. Flamingo Rd., #55 2527 N. Carson Street, Suite 260,
Las Vegas, NV 89121 Carson City, NV 89706
Telephone: (702) 486-1404 Telephone: (775) 684-0730
Fax: (702) 486-1441 Fax: (775) 684-0740
(Page B) 2824 – EL (07/22)
APPLICATION FOR ASSISTANCE
Please complete every
section and answer each question. Sign the application and the
Rights and Obligations form. Failure to complete all sections and questions and/or sign the
application and Rights and Obligations, OR provide the requested documentation noted on
the applica
tion, will delay processing your application and may result in your application
being denied.
A. APPLICANT/HOUSEHOLD INFORMATION
Complete the following for every person living in your home, including yourself
(attach an
additional page if necessary). The first name on the application should be the applicant (person
listed on the utility bill who resides in the home). Provide proof of identity for the applicant.
Ethnicity – Please choose one of the following codes for each household member- H-
Hispanic/Latino, N-Non-Hispanic/Latino, or X-Prefer not to disclose.
Race
– Please choose one of the following codes for each household member: A-Asian, B-
Black
or African American; G – North African; H – Middle Eastern; I-
American Indian or Alaska
Native; J-American Indian or Alaska Native and White; L-Asian and White; M-
Black or African
American and White; N-American Indian or Alaska Native and Black or African American; U-
Native Hawaiian or Other Pacific Islander; W-White; Z-
2 or more combinations not listed above
or X-Prefer not to disclose.
The information below is used to comply with the requirements set forth by NRS 239B.022-
NRS
239B.026. Only the Department of Health and Human Services will have access to this
information. Your responses will be kept private and secure. The information wil
l not be used
for a discriminatory purpose. Providing this information is voluntary.
(Page 1 of 21) 2824 – EL (07/24)
U.S.
Citizen or
Eligible
*Non
citizen
Yes No
What sex were you assigned at birth, such as on your original birth certificate?
Please
choose one of the following codes for each household member: M-Male, F-Female.
How do you describe yourself
Please choose one of the following codes for each household
member: M-Male, F-Female, TM-Transgender Man/Trans Male, TW-
Transgender
Woman/Trans Female, G-Genderqueer/gender non-conforming, D-
Different Identity (Please
specify), X-Prefer not to disclose.
Which of the following best represents your sexual orientation identity?
Please choose one
of the following codes for each household member: S-Straight or Heterosexual, G-Gay, L-
Lesbian, B-Bisexual, N-Not listed (Please specify), X-Prefer not to disclose.
Name
(Last, First, Middle)
(Jr., Sr., III)
Relationship to You
SELF
PLEASE SEE ABOVE
FOR CODES
Ethnicity
Race
Sex Assigned at Birth
How do you describe
yourself?
Sexual Orientation
Identity
Date
of
Birth
(mm/
dd/y
y)
Age
-
Disabled
Yes No
Social
Security
Number
(Page 2 of 21) 2824 – EL (07/23)
Are there additional people in your home? YES NO
If “YES,” list them on a
separate sheet of paper.
Home Address (include apartment or unit number) City State Zip
Mailing Address (If different from your home address.) City State Zip
Home Phone
( )
Day/Message/Cell Phone
( )
E-mail Address
(Page 3 of 21) 2824 – EL (07/23)
*List the names of non-citizen household members authorized as legal residents of the
United States:
*Provide copies of the front and back of their I-551 (Resident Alien Card) with this
application.
B. DWELLING INFORMATION
Renters: Provide a complete signed copy of rent or lease agreement dated within the last 12
months, listing every person living in the home(s). If subsidized, provide signed Housing
documents listing every person in the home, rent and utility rebate.
Buyers/Owners: Provide copy of mortgage statement, or proof of payoff, or current tax
information.
1. Dwelling Type: House Apartment Condo/Townhome Rent Room
Mobile Hom
e D
uplex Motel/Hotel Travel Trailer Studio
Other: _____________________
2. D
welling Cost
: R
ent $____________ Subsidized Rent $____________
Buy $____________ Space Rent $__________ Own
When did you pay off your mortgage?_______________
3. R
ent/Buyers only: Landlord, Project/Complex, Mortgage Company Name
:
_________________________________________
(Page 4 of 21) 2824 – EL (07/23)
Address: _________________________________
Telephone No.: (_____) __________________
4. D
o you reside in subsidized housing where heating and electric are included in t
he
rent? YES NO
IF YES, select all that apply: Section 8 Section 42 Other
D.HELP US BETTER SERVE OTHERS
How did you hear about the Energy Assistance Program? Check one that most applies:
TV Landlord
Radio Previous EAP Participant
Print Media Received Notice in Mail
Social Service Employee Utility Company (flyer or employee)
Friend Other: Please identify___________________
(Page 5 of 21) 2824 – EL (07/23)
D. UTILITY INFORMATION
Energy Providers
ELECTRIC SERVICE
(Attach Copy of Bill)
Check one that applies:
Receive bill from utility company
Electric service included in rent/mortgage
Pay separate bill to landlord for electric
service
(Electric Company Name)
(Electric Account Number)
(Name On Account)
HEATING SERVICE
(Attach Copy of Bill)
Check one that applies:
Receive bill from heating company
Heating service included in rent/mortgage
Pay separate bill to landlord for heating
service
(Heating Company Name)
(Heating Account Number)
(Name On Account)
(Page 6 of 21) 2824 – EL (07/24)
Is the person listed on the account your
landlord? YES NO
(If the account holder does not live with you
provide their address, telephone number,
relationship to you, proof of identity for the
son who is named on the utility bill, and aper
statement authorizing you to apply for benefits
on their behalf.)
Do you have past due charges with your electric
ity and want assistance to pay this debt? util
YES NO
Is the person listed on the account your
landlord? YES NO
(If the account holder does not live with you
provide their address, telephone
number,
relationship to you, proof of identity for the
person who is named on the utility bill, and a
statement authorizing you to apply for benefits
on their behalf.)
ARREARAGE ASSISTANCE (Once every
five years)
Do you have past due charges with your electric
utility and wa
nt assistance to pay this debt?
YES NO
If your energy provider is NV Energy or Southwest Gas, you need to provide a copy of
(Page 7 of 21) 2824 – EL (07/24)
your current utility bill. For all other energy providers, proof of the last 12 months of
usage in dollars and therms, watts and/or gallons
for your current address will be required.
Proof can be in the form of your last 12 months bills or a print-
out from your energy
provider.
ARREARAGE ASSISTANCE (Once every
five years)
E. HOW DO YOU WANT YOUR EAP BENEFIT PAID?
Choose how you want your benefits paid: (Mark ONLY One)
Split my benefit between my electric and heating vendor.
Pay my entire benefit, to my heating vendor
Pay my entire benefit, to my electric vendor
If you choose a split payment your benefit will be split between both of your energy providers
not to exceed your annual usage per provider. The benefit may not be an equal 50/50 split.
If you choose a single payment your benefit will be paid to cover your annual usage for that
provider, and if there is a remaining balance, it will be paid to your second provider.
If you do not choose one of the options above, your benefit will be split between both providers
not to exceed the annual usage per provider.
F. INCOME
1. EARNED INCOME: Does any member of the household, regardless of age, work?
YES NO
If YES, complete the information below: (Include self-employment, business, child
care, housecleaning, odd jobs, temp agencies, and non-profit organization income)
(Page 8 of 21) 2824 – EL (07/23)
NAME OF
PERSON
WORKING
EMPLOYER
DATE
OF HIRE
TYPE OF
WORK
GROSS
PAY
PER
CHECK
HOW
OFTEN
PAID
TIPS
PER
MONT
H
-
List all household members, age 18 or older, who are not currently employed:
NAME OF
PERSON
FORMER
EMPLOYER
DATE
LAST
WORKED
GROSS PAY
PER CHECK
DO YOU EXPECT RE
EMPLOYMENT or
PENDING SSI? If YES,
explain.
Attach copies of all check stubs or other proof of gross income
for at least the last thirty
(30) days even if the person is no longer employed. 1099s and W-2s by themselves are not
acceptable proof of income. EXCEPTION: Self-
employment requires 12 months profit
and loss statements.
(Page 9 of 21) 2824 – EL (07/23)
2. UNEARNED INCOME: Complete the following, indicating who, if anyone, receives money
or benefits from the sources listed below. You must mark YES or NO for each income type and
Y
E
S
N
O
INCOME TYPE
PERSON
RECEIVING
GROSS
AMOU
NT
FREQUE
NCY
Alimony
Boarders / Roomers (Attach notarized proof
of rental or lease)
Child Support
Contribution / Gifts / Church or Charitable
Donations
Educational Assistance / Student Loans
(Attach proof of tuition, books and supplies
for prior TWO semesters)
Food Assistance (Supplemental Nutrition
Assistance Program-SNAP) In Nevada?
Yes No
If No, which State? _____
Foster Care
County Assistance / General Assistance
Interest / Dividends / Annuities / Royalties
Loans
(Page 10 of 21) 2824 – EL (07/23)
Lump Sum Payments (Settlements / Back
Pay, etc.)
Military Income / Allotment
Mining Claims
Panhandling
Pensions / Retirement
Property Rentals / Sale
Railroad Retirement
Room Rental (Attach notarized proof of
rental or lease)
Social Security Benefits (RSDI)
Strike Benefits
Subsidized Housing
Supplemental Security Income (SSI)
Supported Living Arrangement (SLA)
TANF Assistance
Tribal Assistance / Indian General
Assistance (IGA)
(Page 11 of 21) 2824 – EL (07/23)
Trust Income (Provide proof if it is not
accessible)
Unemployment Insurance
Utility Allowance / Rebate Check
Veterans Benefits
Winnings
Worker’s Compensation or Temporary
Disability
Other
(Page 12 of 21) 2824 – EL (07/23)
MEETING EXPENSES:
1. If the household expenses (e.g. rent, utilities, food, etc.) are more than your
household’s income, explain how you are able to meet these expenses.
2.
If someone is helping you meet your expenses or is giving you money, you mus
t
pr
ovide a signed statement from each person that includes their name, address
,
telephone number and amount of help they provided to you during each of the last six
months. Below, fill out the information of the person(s) who provided you a
statement:
Name of Person
Address
Phone Number
Amount
How often
Assisting
Do you expect any changes in the household’s income or benefits? YES NO
If YES, what? __________________________________________
When? ________________________________________________
Changes in income prior to certification will be used to determine eligibility.
(Page 13 of 21) 2824 – EL (07/23)
G. RESPONSIBILITY
Information provided in this application is subject to verification and investigation by federal,
state and local officials. If you make a false or misleading statement, misrepresent, conceal, or
withhold facts, or fail to report changes to establish or maintain eligibility for energy assistance
your benefits may be denied, terminated or reduced. You are responsible for repayment of all
monies, services and benefits for which you were not entitled. Additionally, you may also be
barred from program participation, criminally prosecuted and/or otherwise penalized according
to state and federal law. Initial:____ ____
Have you ever been determined to have committed an Intentional Program Violation (IPV)?
YES
NO
______ If YES, in what State?
Initial: I have read the information in section G. Responsibility
H. AUTHORIZATION
By signing this application, I am authorizing the Department of Health and Human Services to
make any investigation concerning me or any other member of my household which is necessary
to determine eligibility for benefits received or to be received under programs administered by
the Division of Welfare and Supportive Services. I hereby authorize and consent to the release
of any and all information concerning me and/or my household members to the Division of
Welfare and Supportive Services by the holder of the information regardless of the manner or
form held, including by, without limitation, wage information, information made confidential by
law or otherwise privileged under NRS 422A.342 or any other provision of law or otherwise. I
authorize the Energy Assistance Program to release information about my household, to include
energy usage information, to the State of Nevada Housing Division, Weatherization Assistance
(Page 14 of 21) 2824 – EL (07/24)
Program, for potential eligibility in weatherizing my residence. I hereby release the holder of
such information from liability, if any, resulting from the disclosure of the required information.
I ACKNOWLEDGE THAT A REPRODUCED COPY OF THIS AUTHORIZATION
LEGALLY CONSTITUTES AN ORIGINAL COPY.
Initials __________
If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my
rights as an older person to have my identity kept confidential. I hereby release the holder of
information from liability, if any, resulting from the disclosure of the required information.
Initials __________
I consent that the Division of Welfare and Supportive Services or its representatives may survey
my energy usage, advise providers of assistance grants, and status at the time of certification. I
consent that the Division of Welfare and Supportive Services use Social Security Numbers
(SSNs) provided in this application to verify factors of Energy Assistance Program eligibility,
which may include automated data exchange with the Social Security Administration.
I agree to notify the Energy Assistance Program of any changes in my household circumstances
that may affect my energy assistance benefits. I understand failure to report changes may cause
an overpayment which I would be responsible to pay back and could even be prosecuted by a
court of law. I swear I have honestly reported the citizenship of myself and anyone I am applying
for.
Initial: I have read the information in section H. Authorization
(Page 15 of 21) 2824 – EL (07/24)
I. RIGHTS AND OBLIGATIONS
You have the following RIGHTS:
No person will be discriminated against for any reason, e.g., race, age, color, religion, sex,
disability, handicap (including AIDS and AIDS related conditions), political belief or national
origin, in any program administered by the Division of Welfare and Supportive Services. When
the Energy Assistance Program (EAP) pays another agency, institution, or person to provide EAP
services to a household, the provider is not permitted to discriminate for any reason. Violations
of discrimination shall be promptly reported to the Energy Assistance Program office, the
Division of Welfare and Supportive Services Administrator, 1470 College Parkway, Carson City,
Nevada 89706-7924, (775) 684-0500, the U.S. Office for Civil Rights (OCR), Department of
Health and Human Services, 50 United Nations Plaza, San Francisco, California 94102, (415)
437-8310, TDD (415) 437-8311 or by calling toll free 1-800-368-1019.
You have the right to a conference if you believe you have been unfairly treated or a mistake has
been made concerning your eligibility for assistance. To request a conference, write or call the
Energy Assistance Program.
You have the right to a hearing if you are not satisfied with the agency’s action affecting your
assistance if you request the hearing, in writing, within ninety (90) days of the agency’s
action/decision, unless the sole issue for the agency’s action/decision is one of state or federal
law requiring automatic benefit adjustment. You have the right to a hearing if your application is
denied, acted upon erroneously, or not acted upon with reasonable promptness, or if your benefits
have been reduced.
You have the right to a mailed notice of decision telling you if you are eligible for program
benefits and in what amount, to whom payments will be made, and the approximate payment
date(s); or a notice informing you that you are not eligible for program benefits and why.
(Page 16 of 21) 2824 – EL (07/24)
Program staff are required to:
• Inform applicants of the eligibility requirements for the program;
• Counsel on required documents; and/or
• Provide assistance to the applicant when needed.
Initial: ____ ____
You have the following OBLIGATIONS:
Notify the Energy Assistance Program within ten (10) calendar days of any of the following:
• Any change in your household income or household size (number of people residing in
the household);
• If you change utility companies; or
• If you move anytime after submitting your application.
Note: Failure to do so may delay processing your application or result in denial of benefits or a
reduction in benefits.
Respond to any requests for additional information needed to process your application within
ten (10) calendar days. It is your responsibility to ensure the requested materials are mailed or
faxed early enough to meet the deadline provided to you. The Energy Assistance Program is not
responsible for lost or misdirected mail, or faxes. (Be sure your name and SSN or UPI are on all
documents/correspondence.)
Cooperate with the Energy Assistance Program in its efforts to secure all information necessary
to determine eligibility or benefits.
Initial: ____ ____
(Page 17 of 21) 2824 – EL (07/24)
SPECIAL NOTE:
If you are applying for the Energy Assistance Program you may receive help with your utility
bills. But remember, you must keep paying your bills when they are due. If you do not pay them,
the company can charge more money for paying late. The utility company can even turn off your
service and you may be required to pay a deposit before they will turn your service on again. If
you cannot pay your bill, contact the utility company, and try to make payment arrangements.
Persons found guilty of intentionally violating program rules will be ineligible for program
participation for one (1) year for the first violation, two (2) years for the second violation, and
permanently barred from the program for the third violation.
Initial: I have read the information in section I. Rights and Obligations
J. SIGNATURES
I understand if I fail to initial pages 5-6 where indicated on this application, it does not
release me or my household members from those requirements / obligations.
I understand the questions on this application and the penalty for hiding or giving false
information. I certify under penalty of perjury; my answers are correct and complete to
the best of my knowledge and ability. I swear I have honestly reported the citizenship of
myself and anyone I am applying for. I understand the Rights and Obligations as an
applicant for the Energy Assistance Program.
Print Name of Applicant:
Signature of Applicant:
Date:
Print Name of Other Adult Member(s) in Household:
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______________________________________________________________
______________________________________________________________
Signature of Other Adult Member(s) in Household:
Date:
Print Name of Other Adult Member(s) in Household:
Signature of Other Adult Member(s) in Household:
Date:
WITNESS: (Use if applicant cannot read or write or is visually impaired.) I have assisted
with the completion of this application for Energy Assistance Program. The information in
this application has been read to the applicant and I have witnessed the above signature.
Print Name of Witness
Signature of Witness Date
(Page 19 of 21) 2824 – EL (07/24)
IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW,
WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?
(Please check one)
YES NO
If you do not check either box, you will be considered to have decided not to register to vote
at this time.
The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register
to vote at this location. If you would like help in filling out a voter registration application form,
we will help you. The decision whether to seek or accept help is yours. You may fill out the
application form in private.
IMPORTANT NOTICE
: Applying to register or declining to register to vote WILL NOT
AFFECT the amount of assistance you will be provided by this agency.
Signature Date
CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain
confidential.
IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to
register to vote, or your right to choose your own political party or other political preference, you
may file a complaint with the Office of the Secretary of State, Capitol
Complex, Carson City,
Nevada 89710.
(Page 20 of 21) 2824 – EL (07/23)
Blank Page
____________________________
WARNING: GIVING FALSE INFORMATION IS A FELONY AND INCLUDES A CIVIL PENALTY OF UP TO $20,000.
Application No.
STATE OF NEVADA VOTER REGISTRATION APPLICATION
USE BLACK OR BLUE INK ONLY – PLEASE PRINT CLEARLY
All fields are required unless marked Optional. If you do not provide all of the required information, your application to register to vote will not be complete.
1.
Are you a citizen of the United States?
☐
Yes
☐
No
If you checked “No” to the above question, do not complete this form.
Will you be at least 18 years of age on or before election day?
☐
Yes
☐
No
If you checked “No” to the above question but are at least 17 years of age, do you wish to preregister to vote?
☐
Yes
☐
No
If you checked “No” to both of the prior questions, do not complete this form.
2.
Last Name First Name Middle Name Suffix
3.
Nevada Residential Address – See Instructions on Back (No P.O. Box/Business Address) Apt. # City State Zip Code
NV
4.
Mailing Address – If Different From Above (P.O. Box or Mail Service Address Acceptable) Apt. # City State Zip Code
5.
Birth Date (MM/DD/YYYY)
6.
Place of Birth (State or Country)
7.
Telephone Number (Optional)
☐
8.
☐
☐
I have a valid NV Driver’s License or ID Card and that number is: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
I have not been issued a NV Driver’s License
or ID Card. The last 4 digits of my Social Security Number are: XXX – XX - ___ ___ ___ ___
I have not been issued a NV Driver’s License or ID Card, and I do not have a So
cial Security Number. If you select this option, you will be contacted
by your County Election Department for more information once your application is received.
Note: ID numbers provided above are confidential and not available for public inspection.
9.
If applicable, check one of the following:
☐
☐
☐
Military Domestic (or military spouse or dependent) – Only check if you are on active duty and will be absent from your place of registration
Military Overseas (or military spouse or dependent)
U.S. Citizen Overseas
10.
Email Address (Optional) – Email Address is Confidential
☐
☐
☐
☐
☐
☐
☐
11.
CHECK THIS BOX TO RECEIVE A SAMPLE
BALLOT IN LARGER TYPE
12.
Party Registration – Check Only One Box
Democratic Party
Independent American Party
Liberta
rian Party of Nevada
Nonpar
tisan (No Political Party)
Republi
can Party
of imprisonme
nt for a felony conviction. I declare under penalty of perjury that the foregoing is true
Other Party – Write in bel
ow
13.
I swear or affirm I am a U.S. citizen. I will be at least 18 years old by the date of the next election, or if I
indicated in Box 1 above that I am preregistering to vote, I am at least 17 years old. I will have
continuously resided in Nevada at least 30 days in my county and at least 10 days in my precinct before
the next elect
ion at which I intend to vote. The residential address listed herein is my sole legal place of
residence, and I claim no other place as my legal residence. If I am preregistering to vote, I understand
and ack
nowledge that I will be deemed to have registered to vote as of the date of my 18th birthday
unless my prereg
istration is canceled by any of the means or for any of the reasons for canceling voter
registration pursuant to Chapter 293 of the Nevada Revised Statutes. I am not currently serving a term
and corr
ect.
SIGNATURE OF APPLICANT (REQUIRED)
____/____/____
(MM / DD / YYYY)
14.
Your name and residential address where you were last registered to vote (Name Used, Address, State, etc.)
15.
Important! If you are assisting a person to register to vote and you are not a Field Registrar appointed by a County Clerk / Registrar of Voters or an employee of a voter
registration agency, you MUST complete the following. Your signature is required. Failure to do so may be a felony.
Full Name Mailing Address City/State/Zip Code Signature
OFFICIAL USE ONLY. DO NOT WRITE IN THE SHADED AREA BELOW.
DATE STAMP
AGENCY
FIELD REGISTRAR
MAIL
IN
PERSON
☐ OTHER
CANCELLED
INACTIVE
PRECINCT
APPLICATION NO.
☐
☐
☐
☐
RECEIVED BY:
Detach Here Detach Here Detach Here
NAME OF PERSON RETAINING THIS APPLICATION
ELECTION OFFICIAL OR AGENCY
VOTER APPLICATION RECEIPT
(Agency Stamp or Name of Agent, Election Official or (Please Retain Receipt)
Person Retaining Application)
(Contact Information, Address, Telephone, Fax)
Your voter registration information has been transmitted
to your County Election Office for processing. Within 10
days after receiving your information, your County
Election Office will mail your Nevada Voter Registration
Card or a notice that additional information is required to
complete your registration.
APPLICATION NO.
INSTRUCTIONS
Box 1 – PREREGISTRATION: Every citizen of the United States who is 17 years of age or older but
less than 18 years of age and has continuously resided in this state for 30 days or longer may
preregister to vote by any of the means available for a person to register to vote pursuant to
Nevada law. If a person preregisters to vote, he or she shall be deemed to be a registered voter
on his or her 18
th
birthday unless the person’s preregistration has been cancelled or he or she
does not satisfy the voter eligibility requirements.
Box 2 – NAME: Required. Please write your name exactly as it appears on your Nevada Driver’s
License, ID Card, or Social Security Card.
Box 3 – ADDRESS WHERE YOU LIVE: Required. Your home address is the street address assigned
to the location at which you actually reside. If you reside at a location that has not been assigned
a street address, a description of the location at which you actually reside must be provided. A
P.O. Box or business address cannot be listed as a home address.
Box 4 – ADDRESS WHERE YOU RECEIVE MAIL: Optional. Include your mailing address if it is
different than your physical address. Include P.O. Boxes and Mail Service Addresses, if applicable.
Box 8 – IDENTIFICATION: Required. Include your Nevada Driver’s License or Nevada Identification
Card number. If you do not have a driver’s license or identification card issued by a Nevada DMV,
include the last four digits of your Social Security Number. If you do not have a Nevada Driver’s
License or Social Security Number, you will be contacted by your County Election Department for
more information once your application is received.
Box 9 – MILITARY: Required, if applicable. Mark the applicable box.
Box 12 – POLITICAL PARTY AFFILIATION: Required. Mark your choice of a qualified political party,
“Nonpartisan” or “Other.” If you mark “Other,” you may print the name of an unlisted political
party. If you register with a minor political party or as a nonpartisan, you will receive a
nonpartisan ballot for the Primary Election.
Box 13 – DECLARATION: Required. Sign and date. Voting Rights are immediately restored for
all felony convictions upon release from prison.
Box 14 – UPDATING INFORMATION: Optional. You may include the last address where you
were registered to vote. This helps the County Clerk/Registrar of Voters identify you as the
applicant.
Box 15 – ASSISTANCE: Required, if applicable. If you are assisting a person to preregister or
register to vote, you must complete Box 15. FAILURE TO DO SO MAY BE A FELONY.
DEADLINES FOR SUBMITTING APPLICATION:
By Mail – Postmarked by the fourth Tuesday preceding the primary or general election.
In-Person at your local County Clerk’s or Registrar of Voters Office – By the fourth
Tuesday preceding the primary or general election.
Online – By the Thursday preceding the primary or general election. Online Registration
available at: www.RegisterToVoteNV.gov
For Special / Recall Elections – Contact your County Clerk or Registrar of Voters.
SAME-DAY VOTER REGISTRATION: Eligible Nevada voters can register to vote or upda
te
e
xisting voter registration information in person at the polling place either during early voting
or on Election Day.
INTERESTED IN BEING A POLL WORKER? Please contact your local County Clerk or Registrar
of Voters Office.
NOTICE: You are urged to return your application to the County Clerk or Registrar of Voters in
person or by mail. If you choose to give your completed application to another person to return
to the County Clerk or Registrar of Voters on your behalf, and the person fails to deliver the
application to the County Clerk or Registrar of Voters, you will not be preregistered or
registered to vote, as applicable. Please retain the duplicate copy or receipt from your
application to preregister or register to vote.
COUNTY
Carson City Clerk
(775) 887-2087
ELECTION DEPARTMENT ADDRESS
885 East Musser Street, Suite 1025, Carson City, NV 89701
COUNTY
Lincoln Clerk
(775) 962-8077
ELECTION DEPARTMENT ADDRESS
181 North Main Street, Suite 201, Pioche, NV 89043
P.O. Box 90, Pioche, NV 89043
Churchill Clerk
(775) 423-6028
155 North Taylor Street, Suite 110, Fallon, NV 89406
Lyon Clerk
(775) 463-6501
27 South Main Street, Yerington, NV 89447
Clark Registrar
(702) 455-8683
965 Trade Drive, Suite A, North Las Vegas, NV 89030
P.O. Box 3909, Las Vegas, NV 89127
Mineral Clerk
(775) 945-2446
105 South A Street, Suite 1, Hawthorne, NV 89415
P.O. Box 1450, Hawthorne, NV 89415
Douglas Clerk
(775) 782-9014
1616 8
th
Street, 2
nd
Floor, Minden, NV 89423
P.O. Box 218, Minden, NV 89423
Nye Clerk
(775) 482-8127
101 Radar Road, Tonopah, NV 89049
P.O. Box 1031, Tonopah, NV 89049
Elko Clerk
(775) 753-4600
550 Court Street, 3
rd
Floor, Elko, NV 89801
Pershing Clerk
(775) 273-2208
398 Main Street, Lovelock, NV 89419
P.O. Box 820, Lovelock, NV 89419
Esmeralda Clerk
(775) 485-6309
233 Crook Avenue, Goldfield, NV 89013
P.O. Box 547, Goldfield, NV 89013
Storey Clerk
(775) 847-0969
26 South B Street, Drawer D, Virginia City, NV 89440
Eureka Clerk
(775) 237-5263
10 South Main Street, Eureka, NV 89316
P.O. Box 540, Eureka, NV 89316
Washoe Registrar
(775) 328-3670
1001 E. 9th St., Reno, NV, 89512
Humboldt Clerk
(775) 623-6343
50 West 5
th
Street, #207, Winnemucca, NV 89445
White Pine Clerk
(775) 293-6509
1786 Great Basin, Blvd., Suite 3, Ely, NV 89301
Lander Clerk
(775) 635-5738
50 State Route 305, Battle Mountain, NV 89820
FIRST CLASS
STAMP
NECESSARY
FOR MAILING
