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1094 E 8th Street, Reno, NV 89512 Phone: (775) 786-6023
Fax: (775) 786-5743
Community Services Agency Central Intake Application - Page Revised 06/06/2019
Applicant's Information - Please complete the following information for the primary applicant.
First Name M Initial Last Name Suffix Date of Birth
GenderMaleFemale
EthnicityHispanic
Non-Hispanic
Marital StatusSingle Married Legally Separated
Divorced Widowed
DisabledYes
NoVeteran
Yes
No
Active MilitaryYes
No
Foster ParentYes
No
Primary LanguageEnglish
Spanish
Other Specify Other Language
English ProficiencyNone Poor
Moderate ProficientRace
American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White
Other Specify Race:
Primary Phone Number Ext Home Cell
Work Message
I do not have a phone.
Secondary Phone Number Ext Home Cell
Work Message
Living Address Unit City State Zip Code
Mailing Address Unit City State Zip Code
Type of DwellingApartment Single Family House Condo/Townhouse Duplex/Triplex/4-plex
Mobile Home/Trailer Motel/Hotel Shelter Park/Street/Car/CampsiteHousing
Rent Own Does Not Pay Homeless Other Permanent Housing Other
Highest Level of Education CompletedGrade 9 or Less High School Non-Graduate
HS Diploma/GED Some College
Associate's Degree Bachelor's Degree
Master's Degree
Present Employment StatusFull-time (+35 hours/week) Seasonally Employed
Part-time (-35 hours/week) Vocational Training
Student Retired or Disabled
UnemployedApplicant's Primary Income Source
Unemployment Compensation No Income Foster Subsidy
Social Security SSI Cash Aid TANF Cash Aid
Pension/Retirement Child Support Employment
Other Income Specify Other Income: Employer Name:
Total Montly Income
Primary Health CoverageNone Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
Secondary Health CoverageNone Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
1 of 6
1094 E 8th Street, Reno, NV 89512 Phone: (775) 786-6023
Fax: (775) 786-5743
Community Services Agency Central Intake Application - Page Revised 06/06/2019
Does anyone in the home receive any of the following services?
WIC Food Stamps/SNAP TANF Energy Assistance Program
Section 8 Housing Housing Authority Foster Care SSI
Who referred you to us?
Family Friend Outside Agency CSA/HS Referral Community Events Poster/Flyer
Television Newspaper Phone Book Radio Internet Website
Agency Name:
How many people live in your home?
Adults: Children:
Program Applicant Disclosure Statement - (SIGNATURE REQUIRED) I hereby declare that the information contained in this application for program services is true and correct to the best of my knowledge and understanding. No false or misleading statements have been made by me or anyone representing me. The acceptance of the application does not guarantee that services will be performed under any program, and that services are dependent on many things including accurate applications, availability of funding and a determination that the applicant qualifies for the program. I hereby release, discharge, exonerate Community Services agency, their agents and representatives and any person furnishing information or examining information from any and all liability of every nature and kind arising out of the furnishing and inspection of such documents, records, and other information, and this release shall be binding on my legal representatives to use the information that I have provided aggregated with other customers and clients of Community Services Agency for any and all reporting and funding purposes.
Community Services Agency, its agents, partners and funding sources do not discriminate on the basis of race, color, sex, age, religion, national origin, disability, marital status, sexual orientation or ancestry, or any other consideration made unlawful by applicable discrimination laws. "The USDA is a equal opportunity provider and employer."
Applicant's Signature Today's Date
2 of 6
1094 E 8th Street, Reno, NV 89512 Phone: (775) 786-6023
Fax: (775) 786-5743
Community Services Agency Central Intake Application - Page Revised 06/06/2019
Additional Household Member - Please complete the following information for all members of the household.
First Name M Initial Last Name Suffix Date of Birth
GenderMaleFemale
Ethnicity
Hispanic
Non-Hispanic
Marital Status
Single Married Legally SeparatedDivorced Widowed
DisabledYesNo
VeteranYes
No
Active MilitaryYes
No
Foster ParentYes
No
Primary LanguageEnglish
Spanish
Other Specify Other Language
English ProficiencyNone Poor
Moderate Proficient
Specify Race:
Relationship to the Applicant
Spouse Significant Other Parent/Guardian Child Sibling Other Relative Other Non-RelativeHighest Level of Education Completed
Grade 9 or Less High School Non-Graduate
HS Diploma/GED Some College
Associate's Degree Bachelor's Degree
Master's Degree
Present Employment StatusFull-time (+35 hours/week) Seasonally Employed
Part-time (-35 hours/week) Vocational Training
Student Retired or Disabled
UnemployedPrimary Income Source
Specify Other Income: Employer Name:
Total Monthly Income
Primary Health Coverage Secondary Health Coverage
3 of 6
Other
American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White
Unemployment Compensation
Social Security
Pension/Retirement
Other Income
No Income
SSI Cash Aid
Child Support
Foster Subsidy
TANF Cash Aid
Employment
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
Race
1094 E 8th Street, Reno, NV 89512 Phone: (775) 786-6023
Fax: (775) 786-5743
Community Services Agency Central Intake Application - Page Revised 06/06/2019
Additional Household Member - Please complete the following information for all members of the household.
First Name M Initial Last Name Suffix Date of Birth
GenderMale
Female
EthnicityHispanic
Non-Hispanic
Marital StatusSingle Married Legally SeparatedDivorced Widowed
Disabled
YesNo
VeteranYes
No
Active MilitaryYes
No
Foster ParentYes
No
Primary LanguageEnglish
Spanish
Other Specify Other Language
English ProficiencyNone Poor
Moderate ProficientRace
American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander WhiteOther Specify Race:
Relationship to the Applicant
Spouse Significant Other Parent/Guardian Child Sibling Other Relative Other Non-RelativeHighest Level of Education Completed
Grade 9 or Less High School Non-Graduate
HS Diploma/GED Some College
Associate's Degree Bachelor's Degree
Master's Degree
Present Employment StatusFull-time (+35 hours/week) Seasonally Employed
Part-time (-35 hours/week) Vocational Training
Student Retired or Disabled
UnemployedPrimary Income Source
Unemployment Compensation No Income Foster Subsidy
Social Security SSI Cash Aid TANF Cash Aid
Pension/Retirement Child Support Employment
Other Income Specify Other Income: Employer Name:
Total Monthly Income
Primary Health Coverage Secondary Health Coverage
4 of 6
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
1094 E 8th Street, Reno, NV 89512 Phone: (775) 786-6023
Fax: (775) 786-5743
Community Services Agency Central Intake Application - Page Revised 06/06/2019
Additional Household Member - Please complete the following information for all members of the household.
First Name M Initial Last Name Suffix Date of Birth
Gender
FemaleMale
Ethnicity
Non-Hispanic
HispanicMarital Status
WidowedDivorcedLegally SeparatedMarriedSingle
Disabled
No
Yes
Veteran
No
YesActive Military
No
YesFoster Parent
No
YesPrimary LanguageOther
Spanish
English Specify Other Language
English Proficiency
ProficientModerate
PoorNone
RaceAmerican Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White
Other Specify Race:Relationship to the Applicant
Other Non-RelativeOther RelativeSiblingChildParent/GuardianSignificant OtherSpouseHighest Level of Education Completed
Master's Degree
Bachelor's DegreeAssociate's Degree
Some CollegeHS Diploma/GED
High School Non-GraduateGrade 9 or LessPresent Employment Status
Unemployed
Retired or DisabledStudent
Vocational TrainingPart-time (-35 hours/week)
Seasonally EmployedFull-time (+35 hours/week)
Primary Income SourceUnemployment Compensation No Income Foster Subsidy
Social Security SSI Cash Aid TANF Cash Aid
Pension/Retirement Child Support Employment
Other Income Specify Other Income: Employer Name:
Total Monthly Income
Primary Health Coverage Secondary Health Coverage
5 of 6
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
1094 E 8th Street, Reno, NV 89512 Phone: (775) 786-6023
Fax: (775) 786-5743
Community Services Agency Central Intake Application - Page Revised 06/06/2019
Additional Household Member - Please complete the following information for all members of the household.
First Name M Initial Last Name Suffix Date of Birth
GenderMaleFemale
EthnicityHispanic
Non-Hispanic
Marital StatusSingle Married Legally Separated
Divorced Widowed
DisabledYes
NoVeteran
Yes
No
Active MilitaryYes
No
Foster ParentYes
No
Primary LanguageEnglish
Spanish
Other Specify Other Language
English ProficiencyNone Poor
Moderate ProficientRace
American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White
Other Specify Race:
Relationship to the Applicant
Spouse Significant Other Parent/Guardian Child Sibling Other Relative Other Non-RelativeHighest Level of Education Completed
Grade 9 or Less High School Non-Graduate
HS Diploma/GED Some College
Associate's Degree Bachelor's Degree
Master's Degree
Present Employment StatusFull-time (+35 hours/week) Seasonally Employed
Part-time (-35 hours/week) Vocational Training
Student Retired or Disabled
UnemployedPrimary Income Source
Unemployment Compensation No Income Foster Subsidy
Social Security SSI Cash Aid TANF Cash Aid
Pension/Retirement Child Support Employment
Other Income Specify Other Income: Employer Name:
Total Monthly Income
Primary Health Coverage Secondary Health Coverage
6 of 6
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
None Medicaid Medicare Direct Purchase
Children's Health Insurance (CHIP) Employer Provided
Military Health Insurance
State Health Insurance for Adults
Other Coverage...... Specify:
