Application Form (2905-EG) - Nevada Division of Welfare ...

INJURIES/ACCIDENTS SETT
57. Have you or anyone in your household been injured or in an accident in the last 12 months? YES NO
If “YES,” Who? When?
Was medical treatment received for this injury/accident? YES NO If “YES,” When?
Is there a pending lawsuit because of the injury/accident? YES NO
If “YES,” What is the Attorney’s Name
Attorney’s Address
Did the injury or accident occur while in the custody of law enforcement? YES NO
58. Have you or anyone in your household received or expect to receive an insurance reimbursement,
payment or legal settlement? YES NO
If “YES,” Who? When? How Much? $
From Where?
For Official Use Medical Coverage and TPL.
ABSENT PARENT INFORMATION NCPM
59. Is the father/mother of the child(ren) you are applying for:
(Check one) living somewhere else disabled or deceased
60. If anyone in your home is pregnant, is the father of the unborn in the home? YES NO
If “YES,” Who is the father?
Complete the following form with information about the absent parent9) of your child(ren) who is not living with you
(including the parent of an unborn child). If there is more than one possible parent, complete a form for each one.
Also, please complete a form for your parent(s) if you are under 18 and are not living with them. Please provide as
much information as possible.
*Please make copies or request additional copies of this page for additional parents.
For official Use Child Support
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