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

EARNED INCOME/WORK HISTORY JINC/SELF/OINC/QUIT/STRK
23. Are you or any person(s) in your household currently working, including self employment? YES NO
If “YES,” Who is employed? Hourly Wage? $ Hours worked per week?
How often are they paid? Tips received per month? $
Start Date? / /
Employer’s Name Employer’s Telephone
Employer’s Address
If “YES,” for additional household members:
Who is employed? Hourly Wage? $ Hours worked per week?
How often are they paid? Tips received per month? $
Start Date? / /
Employer’s Name Employer’s Telephone
Employer’s Address
If more than two persons are currently working, please attach an additional sheet of paper.
24. Have you or any persons(s) in your household had a job that ended in the last three months? YES NO
Who was employed? Hourly wage? $ Hours worked per week?
How often were they paid? Tips received per month? $
Employer’s Name Start Date? / / When did the job end? / /
Employer’s Address Employer’s Telephone
Reason for leaving? Quit Fired Leave of Absence Applied Worker’s Compensation Other
If “YES,” for additional house members:
Who was employed? Hourly Wage? $ Hours worked per week?
How often were they paid? Tips received per month? $
Employer’s Name Start Date? / / When did the job end? / /
Employer’s Address Employer’s Telephone
Reason for leaving? Quit Fired Leave of Absence Applied Worker’s Compensation Other
25. Are you or any person(s) in your household currently registered with a Temporary Employment
Service/Agency? YES NO
If “YES,” Who? Which Service/Agency?
26. Are you or any person(s) in your household currently on Strike? YES NO
If “Yes,” Who?
27. Do you or any person(s) in your household work in exchange for food, shelter or something else? YES NO
If “YES,” Who? What do they receive for their work?
What is the value of this exchange? $ When did this begin?
For Official Use – Earned Income
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