Steve Sisolak

DEPARTMENT OF Dena Schmidt

Governor
HEALTH AND HUMAN SERVICES Administrator
Richard Whitley, MS
Director
AGING AND DISABILITY SERVICES DIVISION
Helping people. It’s who we are and what we do.
__________________________________________________________________________________________________

COMMUNITY BASED CARE PROGRAM

APPLICATION
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, LET US KNOW.

COMMUNITY BASED CARE (CBC) PROGRAMS YOU MAY APPLY FOR:

COPE - Community Service Options Program for the Elderly

COPE provides services to seniors to help them maintain independence in their own homes as
an alternative to a long-term care facility. COPE services include the following non-medical
services: Case Management, Homemaker, Social Adult Day Care, Adult Companion, Attendant
Care, Personal Emergency Response System, Chore and Respite.

ELIGIBILITY - Must be 65 years or older and be at risk of long-term care facility placement
within 30 days without services to keep them in their home and community. Priority given to
those meeting criteria of Nevada Revised Statute (NRS) 426 – unable to bathe, toilet and feed
self without assistance.

PAS - Personal Assistance Services

PAS provides community-based, in home services to enable adult persons with severe physical
disabilities to remain in their own homes and avoid placement in a long-term care facility. PAS
services include authorizations for Personal Care Services assisting an individual with daily
tasks such as bathing, dressing, grooming, toileting, transferring/ambulating, eating,
housekeeping, shopping, laundry, and meal preparation. PAS recipients may share in the cost
of their services, based upon a sliding scale formula.

ELIGIBILITY -- Applicants must be age 18 or over and have a severe physical disability as
determined by a licensed medical professional outlined in NAC 427A. Note: PAS Services are
for those that do not meet the financial criteria for Nevada Medicaid or are waiting for the Home
and Community Based Services Waiver for the Frail Elderly (HCBS FE) or Home and
Community Based Services Waiver for Persons with Physical Disabilities (HCBS PD). Per
Nevada Administrative Code (NAC) 427A in order for an application to be considered complete,
it must be submitted with a written statement from a licensed physician, physician assistant or
registered nurse certifying the applicant’s need for essential personal care. The applicant may
submit a written statement, or, a completed CBC-423 form, both of which are required to be
signed and dated by a medical professional as noted above. If this statement/CBC-423 form is
not returned with the application, the application will not be considered a referral for the PAS
program.

Homemaker Program
The Homemaker Program provides in-home supportive services for seniors and persons with
disabilities who require assistance with Instrumental Activities of Daily Living (IADL) including
light housekeeping, shopping, meal preparation and laundry to prevent or delay placement in a
long-term care facility.

Eligibility-- Must be age 60 or older, or be diagnosed with a disability by the Social Security
Administration, and demonstrate a substantial limitation in their ability to complete their IADL’s.

CBC-APPLICATION (1-21)
Page 1 of 8
 HCBS FE Waiver - Home and Community Based Services Waiver for the Frail Elderly

The HCBS FE Waiver authorizes services to seniors to help them maintain independence in their
own homes and communities as an alternative to long-term care facility placement.
HCBS FE Waiver services include the following: Case Management, Homemaker, Social
Adult Day Care, Adult Companion, Personal Emergency Response System, Chore, Respite,
Augmented Personal Care provided in residential care settings and access to State Plan Personal
Care Services.

ELIGIBILITY -- Must be 65 years or older; at risk of long-term care facility placement within 30 days
without services; and require at least one monthly HCBS FE Waiver service. Must apply for and be
determined financially eligible for Medicaid through the Division of Welfare and Supportive Services
(DWSS).

HCBS PD Waiver - Home and Community Based Services Waiver for Persons with Physical Disabilities

The HCBS PD Waiver authorizes services to individuals who have been diagnosed with a physical
disability to help them maintain independence in their own homes and communities as an alternative
to long-term care facility placement. HCBS PD Waiver services include the following: Case
Management, Attendant Care, Homemaker, Chore, Respite, Assisted Residential Care,
Environmental Accessibility Adaptations, Specialized Medical Equipment/Supplies, Personal
Emergency Response System (PERS), Home Delivered Meals and access to State Plan Personal
Care Services.

ELIGIBILITY -- Must be 18 years or older; at risk of long-term care facility placement within 30 days
without services, must be certified as physically disabled by the Division of Health Care Financing and
Policy (DHCFP) Central Office Physician Consultant; and require at least one monthly HCBS PD
Waiver service. Must apply for and be determined financially eligible for Medicaid through the
Division of Welfare and Supportive Services (DWSS).

Financial Eligibility
Must apply for and be determined financially eligible by ADSD for COPE, PAS and Homemaker
programs, and by DWSS for the HCBS FE and HCBS PD Waivers.
Please refer to adsd.nv.gov for more information.

To report suspected abuse, neglect, exploitation, isolation or abandonment of vulnerable

adults, age 18-59, in addition to persons 60 years and older and/or to report complaints to
the Adult Rights Intake unit, please utilize these phone numbers:

Las Vegas/Clark County (702) 486-6930

Statewide/All Other Areas (888) 729-0571

If an older person or vulnerable person is in immediate danger, the local police, sheriff's
office or emergency medical service should be contacted. If the person is not in immediate
danger, the report should be made via one of the designated phone numbers for each
Regional Office.

CBC-APPLICATION (1-21)
Page 2 of 8
 READ THIS PAGE CAREFULLY BEFORE FILLING OUT THE APPLICATION

1. Read each page carefully and answer every question. If the answer is "none," then write in "NONE."
Failure to answer all questions on the application may cause a delay in processing times.

2. If you need help filling out the form, you may want to ask your family, a friend or a case manager from
the Community Based Care unit.

3. Remember, you are certifying to the correctness of your answers whether you are completing the form
yourself, or acting for another person who is unable to complete the form.

Community Based Care will verify the answers you give on this form. Willful concealment of income or
assets could result in a denial or termination of program eligibility.

4. If you are applying for someone other than yourself, check boxes and fill out form as needed in regards
to the person who will be receiving services.

5. Verifications of income and resources will be needed to process the application. If the verifications are
not received with the application, an intake case manager will request the required documents.

PLEASE RETURN THE COMPLETED APPLICATION TO THE APPROPRIATE OFFICE LOCATION BELOW

ADSD Carson City Office

Community Based Care
3416 Goni Road, Suite D-132
Carson City, NV 89706
(775) 687-0574 Fax
CBCNorthSupport@adsd.nv.gov
(775) 687-4210

ADSD Elko Regional Office

Community Based Care
1010 Ruby Vista Drive, Suite 104
Elko, NV 89801
(775) 753-8543 Fax
CBCNorthSupport@adsd.nv.gov
(775) 738-1966

ADSD Las Vegas Regional Office

Community Based Care
3320 W Sahara Ave, Suite 100
Las Vegas, NV 89102
(702) 486-3569 Fax
CBCSouthIntake@adsd.nv.gov
(702) 486-3545

ADSD Reno Regional Office

Community Based Care
9670 Gateway Drive, Suite 100
Reno, NV 89521
(775) 688-2969 Fax
CBCNorthSupport@adsd.nv.gov
(775) 687-0800

*Ask for CBC intake if you have any questions on filling out the
application

CBC-APPLICATION (1-21)
Page 3 of 8
 COMMUNITY BASED CARE PROGRAM APPLICATION
Personal Assistance Services (PAS) Community Service Options Program for the Elderly (COPE)
Homemaker HCBS Frail Elderly (FE) Waiver HCBS Physical Disabilities (PD) Waiver

Demographic Information
Name of Applicant (Last, First, Middle): Social Security Number: Date of Birth:

Street Address: Medicare Number: Age:

City, State, Zip Code: Marital Status: Race/Ethnicity:

Telephone Number: Email Address:

Secondary Phone Number: Who is Completing the Application:

Referring Party and Relationship: Phone Number:

Current Living Situation: Alone Living with Family Own Home Living With Roommate Apartment
Skilled Nursing Facility Group Home/Assisted Living Other:
Name of Facility/Group Home/Assisted Living:

Is the Applicant Currently in a Hospital or Nursing Facility?: Yes No

If Yes, Name and Address of Facility:
Anticipated Discharge Date (If known):
Does Applicant have a Power of Attorney (POA), Guardian, or Supported Decision Making Arrangement? Yes No
If Yes, Name and Phone Number:

Applied for Medicaid benefits before? Yes No Medicaid Number:

Has Applicant ever been disqualified for Medicaid? Yes No Veteran: Yes No Claim #:
Reason: Dates of Service:
Other Medical Insurance: Yes No If Yes, Name and Policy Number:

All Persons Residing With Applicant (SSN and Marital Status needed for Applicant and Spouse Only)
Name: Social Security #: DOB: Sex: Marital Status: Relationship to Applicant:

CBC-APPLICATION (1-21) Page 4 of 8

 HOUSEHOLD is defined as:
The applicant/recipient, their spouse, and any minor dependent child(ren), under the age of 18 residing in the home more than ½
time.

Income – List Anyone in the Household including Applicant

Income Type: Source: Received by Whom? Gross Amount: Frequency:

Social Security
(RSDI) $
Social Security
(RSDI) $
Supplemental
Security Income
$
(SSI)
Supplemental
Security Income
$
(SSI)

Veterans Benefits
$

Job Income $

Pension $

IRA/401K
$
Distributions

OTHER: $

OTHER: $

OTHER: $

Has applicant applied for but not yet received any other income? Yes No

Date Applied:

If Yes, who will be receiving and from what source?

CBC-APPLICATION (1-21)
Page 5 of 8
 Resources – List all Owned or Shared Ownership

Resource Type: Owner(s): Source/Company: Value:

Savings Account $

$
Savings Account
$
Checking Account
$
Checking Account
$
Trust
$
Savings Bond
$
Safe Deposit Box
$
IRA

401K $

$
Burial Insurance
$
Life Insurance
$
Cash on Hand
$
Vehicle
$
Vehicle
$
Vehicle
$
Other
$
Other

Has the applicant, within 60 months of the date of this application, divested or transferred his or her assets in
an attempt to qualify for services from the program for which they are applying? Yes No

If Yes, where were the assets divested or transferred from?

If Yes, date

CBC-APPLICATION (1-21)
Page 6 of 8
 Medical Expenses - Personal Assistance Services ONLY
Include Expenses Paid For By Applicant Only

Medical Expense: Company/ Amount paid: Frequency of Payments:

Source:

Prescriptions $
Medical Insurance/
Premiums $

Other $
Other $
Other $

Social/Health Information
Diagnosis: Physician Name/Phone Number:

Does the Applicant have Decision Making Difficulties?: Yes No Unknown

Does the Applicant have Short Term Memory Difficulties?: Yes No Unknown
Other Care Needs:

Current Services Receiving (Hospice, Home Health etc.):

Does the Applicant Need Help With Any of the Following? Does the Applicant Use Any of the Following Equipment?
(check all that apply) (check all that apply)
☐ Bathing ☐ Eating ☐ Cane
☐ Dressing ☐ Mobility Wheelchair
☐ Grooming ☐ Transfers Walker
☐ Toileting Other:

Service Needs
Is the Applicant in need of any of the following services (check all that apply):
☐ Group Home or Assisted Living Placement
☐ Homemaker services
☐ Personal Emergency Response System (PERS)
☐ Respite
☐ Adult Day Care/Companion services
☐ Environmental Accessibility Adaptations for the home
☐ Durable Medical Equipment
☐ Home Delivered Meals

CBC-APPLICATION (1-21)
Page 7 of 8
Signature and Affirmation
I hereby apply for services through Aging and Disability Services Division (ADSD). I certify all the information is true and
correct to the best of my knowledge and no facts have been omitted.
I make this application with the understanding:
• I authorize and consent to the release of any and all information concerning me and my family to ADSD by the
holder of the information, regardless of the manner or form held (including, without limitation, information made
confidential by law or otherwise). I release the holder of such information from any liability resulting from the
disclosure of the required information.
• I will report any changes in circumstances within 10 days, including changes in my income, assets, living situation,
or abilities.
• I will report any additional income or assets I receive within 30 days of receipt
• I authorize ADSD to contact my employer to obtain wage information.
• I will furnish any additional information which may be required to determine eligibility.
• I will notify ADSD when I no longer need services
• I understand, if I am eligible for Medicaid, I must pursue eligibility through them and depending on the outcome, my
services and eligibility through the ADSD State Programs (PAS, COPE or Homemaker) may be affected.
By signing this application, you are authorizing the Department of Health and Human Services to make investigations
necessary to determine eligibility for benefits you receive or will receive under FE/PD/COPE/PAS/HOMEMAKER program.
You understand that information gathered during the assessment process may be shared with ADSD sister state
agencies and contracted service providers to ensure adequate care is authorized and received. Information provided to
ADSD may be verified or investigated by state officials including Quality Control staff. If you do not cooperate in the
investigation, your benefits may be denied or terminated. If you make false or misleading statements, misrepresent,
conceal or withhold facts necessary to ADSD to make an accurate determination of benefits, or alter any documents, your
benefits may be denied, terminated, or reduced. You may be held responsible for repayment of all monies, services and
benefits for which you were not entitled. Additionally, you may be disqualified from receiving benefits in the future and
criminally prosecuted. You understand the law provides penalties for persons hiding facts or not telling the truth.

This authorization constitutes a full and complete release from any liability from disclosure of such information. A
reproduced copy of this authorization legally constitutes an original copy.

ADSD provides services without discrimination of any kind due to race, national origin, color, gender, religion, age, or
disability (including AIDS and related conditions) as required by federal regulations.

Signature or Mark of Applicant Date

Authorized Representative Print and Sign Date

Authorized Representative Relationship to Applicant (Power of Attorney, Guardian etc.)

Please provide proof of guardianship, POA, etc.

ADSD Case Manager Date

CBC-APPLICATION (1-21)
Page 8 of 8
 Aging and Disability Services Division

Voter Registration Inquiry Form

New Applicant/Certification Recert Change of Address Other
(eligibility redeterm; annual review, etc.) (not applying for ADSD services)

If you are not registered to vote where you live now, would you like to apply to register to vote?

Yes Application mailed as requested via phone No Already registered

Applying to register or declining to register to vote will not affect the amount of assistance that you
will be provided by this agency.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED
NOT TO REGISTER TO VOTE AT THIS TIME.

If you would like help in filling out the 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.

If you believe that someone has interfered with your right to register or to decline to register to vote,
your right to privacy in deciding whether to register or in applying to register to vote, or your right to
choose your own political party or other political preference, you may file a complaint with the
County Clerks and Registrars where you reside.

________________________________________________ ______________________
Signature Date

________________________________________________ ______________________
Please print name ADSD Representative
(when individual does not sign)

DIVISION USE ONLY

OUTCOME: (Required if participant gave a “YES” response above)

Individual completed application in office or assistance was provided by staff during home visit and
brought back to the office for submission to Elections Dept.

Individual took application with them to complete and submit to Elections Dept.

Application mailed to individual with other Agency forms or at the request of the individual.

Submission: Upon completion of this form immediately submit to your Site Voter Registration Coordinator.
Please submit immediately for accurate and timely reporting

Aging and Disability Services Division

VR 32 – 1 VR Inquiry (Declination) Form REV May 2016
 STATE OF NEVADA VOTER REGISTRATION APPLICATION Application No.
Clear Form USE BLACK OR BLUE INK ONLY – PLEASE PRINT CLEARLY
IA52216
WARNING: GIVING FALSE INFORMATION IS A FELONY AND INCLUDES A CIVIL PENALTY OF UP TO $20,000.
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 of America? ☐ 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 Social 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)
Clear Military Information
☐ U.S. Citizen Overseas
Email Address (Optional) – Email Address is Confidential 11.
10.
☐ CHECK THIS BOX TO RECEIVE A SAMPLE
BALLOT IN LARGER TYPE
12. Party Registration – Check Only One Box 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
☐ Democratic Party
continuously resided in Nevada at least 30 days in my county and at least 10 days in my precinct before
☐ Independent American Party the next election at which I intend to vote. The residential address listed herein is my sole legal place of
☐ Libertarian Party of Nevada residence and I claim no other place as my legal residence. If I am preregistering to vote, I understand
and acknowledge that I will be deemed to have registered to vote as of the date of my 18th birthday
☐ Nonpartisan (No Political Party) unless my preregistration is cancelled by any of the means or for any of the reasons for
☐ Republican Party cancelling voter registration pursuant to Chapter 293 of the Nevada Revised Statutes. I
am not currently serving a term of imprisonment for a felony conviction. I declare under
☐ Other Party – Write in below penalty of perjury that the foregoing is true and correct.

SIGNATURE OF APPLICANT (REQUIRED) PRINT

( MM / DD / YYYY )

14. Your name and residential address where you were last registered to vote (Optional) – (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 is 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 CANCELLED APPLICATION NO.
IA52216
☐ FIELD REGISTRAR
INACTIVE RECEIVED BY:
☐ MAIL
☐ IN PERSON PRECINCT
☐ OTHER

 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 (Contact Information, Address, Telephone, Fax) (Please Retain Receipt)
Person Retaining Application) 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.
IA52216
 INSTRUCTIONS PRINT

Box 1 – PREREGISTRATION: Every citizen of the United States who is 17 years of age or older but Box 13 – DECLARATION: Required. Sign and date. Voting Rights are immediately restored
less than 18 years of age and has continuously resided in this state for 30 days or longer may for all felony convictions upon release from prison.
preregister to vote by any of the means available for a person to register to vote pursuant to Box 14 – UPDATING INFORMATION: Optional. You may include the last address where you
Nevada law. If a person preregisters to vote, he or she shall be deemed to be a registered voter were registered to vote. This helps the County Clerk / Registrar of Voters identify you as the
on his or her 18th birthday unless the person’s preregistration has been cancelled or he or she applicant.
does not satisfy the voter eligibility requirements. Box 15 – ASSISTANCE: Required, if applicable. If you are assisting a person to preregister or
Box 2 – NAME: Required. Please write your name exactly as it appears on your Nevada Driver’s register to vote, you must complete Box 15. FAILURE TO DO SO IS A FELONY.
License, ID Card, or Social Security Card. DEADLINES FOR SUBMITTING APPLICATION:
Box 3 – ADDRESS WHERE YOU LIVE: Required. Your home address is the street address assigned  By Mail – Postmarked by the fourth Tuesday preceding the primary or general election.
to the location at which you actually reside. If you reside at a location that has not been assigned  In Person at your local County Clerk’s or Registrar of Voters Office – By the fourth
a street address, a description of the location at which you actually reside must be provided. A Tuesday preceding the primary or general election.
P.O. Box or business address cannot be listed as a home address.  Online – By the Thursday preceding the primary or general election. Online Registration
Box 4 – ADDRESS WHERE YOU RECEIVE MAIL: Optional. Include your mailing address if it is available at:www.RegisterToVoteNV.gov
different than your physical address. Include P.O. Boxes and Mail Service Addresses, if applicable.  For Special / Recall Elections – Contact your County Clerk or Registrar of Voters.
Box 8 – IDENTIFICATION: Required. Include your Nevada Driver’s License or Nevada Identification SAME-DAY VOTER REGISTRATION: Eligible Nevada voters can register to vote or update
Card number. If you do not have a driver’s license or identification card issued by a Nevada DMV, existing voter registration information in person at the polling place either during early voting
include the last four digits of your Social Security Number. If you do not have a Nevada Driver’s or on Election Day.
License or Social Security Number, you will be contacted by your County Election Department for INTERESTED IN BEING A POLL WORKER? Please contact your local County Clerk or Registrar
more information once your application is received. of Voters Office.
Box 9 – MILITARY: Required, if applicable. Mark the applicable box.
NOTICE: You are urged to return your application to the County Clerk or Registrar of Voters in
Box 12 – POLITICAL PARTY AFFILIATION: Required. Mark your choice of a qualified political party,
person or by mail. If you choose to give your completed application to another person to return
“Nonpartisan” or “Other.” If you mark “Other,” you may print the name of an unlisted political
to the County Clerk or Registrar of Voters on your behalf, and the person fails to deliver the
party. If you register with a minor political party or as a nonpartisan, you will receive a
application to the County Clerk or Registrar of Voters, you will not be preregistered or
nonpartisan ballot for the Primary Election.
registered to vote, as applicable. Please retain the duplicate copy or receipt from your
application to preregister or register to vote.
COUNTY ELECTION DEPARTMENT ADDRESS COUNTY ELECTION DEPARTMENT ADDRESS
Carson City Clerk 885 East Musser Street, Suite 1025, Carson City, NV 89701 Lincoln Clerk 181 North Main Street, Suite 201, Pioche, NV 89043
(775) 887-2087 (775) 962-8077
Churchill Clerk 155 North Taylor Street, Suite 110, Fallon, NV 89406 Lyon Clerk 27 South Main Street, Yerington, NV 89447
(775) 423-6028 (775) 463-6501
Clark Registrar 965 Trade Drive, Suite A, North Las Vegas, NV 89030 Mineral Clerk 105 South A Street, Suite 1, Hawthorne, NV 89415
(702) 455-8683 P.O. Box 3909, Las Vegas, NV 89127 (775) 945-2446 P.O. Box 1450, Hawthorne, NV 89415
Douglas Clerk 1616 8th Street, 2nd Floor, Minden, NV 89423 Nye Clerk 101 Radar Road, Tonopah, NV 89049
(775) 782-9014 P.O. Box 218, Minden, NV 89423 (775) 482-8127 P.O. Box 1031, Tonopah, NV 89049
Elko Clerk 550 Court Street, 3rd Floor, Elko, NV 89801 Pershing Clerk 398 Main Street, Lovelock, NV 89419
(775) 753-4600 (775) 273-2208 P.O. Box 820, Lovelock, NV 89419
Esmeralda Clerk 233 Crook Avenue, Goldfield, NV 89013 Storey Clerk 26 South B Street, Drawer D, Virginia City, NV 89440
(775) 485-6309 P.O. Box 547, Goldfield, NV 89013 (775) 847-0969
Eureka Clerk 10 South Main Street, Eureka, NV 89316 Washoe Registrar 1001 East Ninth Street, Bldg A, Rm 135A, Reno, NV 89512
(775) 237-5262 P.O. Box 694, Eureka, NV 89316 (775) 328-3670
Humboldt Clerk 50 West 5th Street, #207, Winnemucca, NV 89445 White Pine Clerk 801 Clark Street, Suite 4, Ely, NV 89301
(775) 623-6343 (775) 293-6509
Lander Clerk 50 State Route 305, Battle Mountain, NV 89820
(775) 635-5738

FIRST CLASS
STAMP
NECESSARY
FOR MAILING