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

RESOURCES BANK/LIFE/PROP
30. Please mark the “YES” box for each of the types of resources you or any person(s) in your household has, even if jointly
owned with someone outside the household. If you do not check the “yes” box for any of the resources below you are
acknowledging neither you or any person(s) in your household have any resources:
BANK ACCOUNTS
YES
YES
YES
YES
TYPE OF ACCOUNT OWNER(S) NAME OF BANK VALUE
Savings Account $
Checking Account $
Credit Union Account $
Minor Savings $
Business Account $
Christmas Club
Account
$
Educational Savings
Account
$
Patient Trust Fund $
Individual Indian
Money Account
LIFE INSURANCE/TRUSTS/BURIALS
$
TYPE OF ACCOUNT OWNER(S)
NAME OF COMPANY
OR BANK
FACE VALUE
Life Insurance $ /CSV$
Available Trusts $
Unavailable Trusts $
Burial Funds/Plans $ /CSV$
Life Estates
INVESTMENTS & RETIREMENT ACCOUNTS
TYPE OF ACCOUNT OWNER(S) NAME OF BANK OR COMPANY VALUE
Savings Bonds $
Stocks or Bonds $
Certificates of
Deposit
Individual
$
Retirement Accounts
(IRA)
$
Keogh Account
(401K)
$
Annuities $
PERSONAL PROPERTY
TYPE OF PROPERTY OWNER(S) LOCATION
CONTENTS OR TYPE OF
RESOURCE
Safe Deposit Box $
Livestock $
Land Mineral Rights $
Mining Claims $
Business Equipment/
Inventory
$
5
ACCOUNT
NUMBER
(Please list the
last 4 numbers
only)
POLICY OR
ACCOUNT
NUMBER
(Please list the last
4 numbers only)
ACCOUNT
NUMBER
(Please list the last
4 numbers only)
CURRENT OR
MARKET
VALUE