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TANF TANF TANF TANF TANF TANF TANF TANF SNAP SNAP SNAP SNAP SNAP SNAP SNAP SNAP Service Agreement (MH) SUPPORTED LIVING ARRANGEMENT Client Name: __________________________________________________________________ Client Address: __________________________________________________ Apt # ___________ __________________________________________________________________ SSN ____/____/____ - ____/____ - ____/____/____/____ Case # ______________________ Monthly Client Resources Net Amount Earnings From Employment Employer: N/A Other Other AGREEMENT BETWEEN: The Client, the Provider and the State of Nevada, Division of Mental Hygiene and Mental Retardation, Kinkead Building, Room 602, 505 E. King Street, Carson City, Nevada 89710. Agency (Circle) SNAMHS NMH RURAL CLINICS SSI RSDI (SSDI) Other Benefits: Total Client Resources HUD SHELTER PLUS CARE (Circle) YES NO This Agreement shall be in effect beginning: __________________________________________________ through __________________________________________________ (Month, Day, Year) (Month, Day, Year) This Agreement is: (Circle) New Renewal Amendment (If amended, dates of original Agreement) ____________________________ through ____________________________ ROOM AND BOARD BUDGET PLAN SPECIALIZED SERVICES Monthly Expenses Client Other State Hours Hourly Rate Cost Retained Earning Case Management Personal Needs Direct Services Food Direct Services Rent Direct Services Utilities Direct Services Phone Direct Services Client Travel Other Medical Staff Travel N/A N/A Other Administration N/A N/A Room & Board Total Services Total N/A Spec. Svcs. Total ONE-TIME COSTS FOR THE MONTH OF: _________________________ $_____________ List one-time expenses: ___________________________________________________________ ______________________________________________________________________________ Monthly Total Last Monthly Total Difference Explain why contract increased, remained the same or decreased: _______________________________________________________________________________________________________________ SEE REVERSE SIDE OF AGREEMENT FOR ADDITIONAL CONDITIONS OF THE AGREEMENT. MY SIGNATURE AFFIRMS THAT I AGREE WITH ALL CONDITIONS OF THIS AGREEMENT. __________________________________________________________________________________ Signature of Provider Date Provider Name: _______________________________________________________ Provider Address: _______________________________________________________ _______________________________________________________ Tax ID Number: _______________________________________________________ I authorize the identified division agency and provider to exchange information from my case records for coordination of services and planning. Other uses are forbidden; this consent expires with this agreement. ______________________________________________________________________________ Signature of Client Date ______________________________________________________________________________ Case Manager Date ______________________________________________________________________________ Housing Coordinator Date ______________________________________________________________________________ Business Office Date ______________________________________________________________________________ Administration Date All SLA discrepancies are to be clarified with the issuing SLA agency (e.g. DPBH and/or the contracted providers). Some SLA providers may issue cash assistance directly to the individual as part of a self- sufficiency plan or because the customer resides in rural or outlying areas where provider services are limited. A-736.5 INCOME Division of Social Services Eligibility and Payments Manual 26 Jun 26 MTL 09/26 In-Home Family Preservation Program (FPP)/Supported Living Arrangement (SLA)