EAP - Attach EE - EAP Intake Site Log.pdf

This document is an Intake Site Log form used by the State of Nevada, Department of Human Services, Division of Social Services, for the Energy Assistance Program (EAP). The form serves as a tracking and processing tool for intake sites administering EAP applications across Nevada, with two primary office locations listed: one in Carson City at 2527 N. Cason St., Suite 260, and another in Las Vegas at 3330 E. Flamingo Rd., #55. The log is designed to record intake site information including contact person details, address, telephone number, and email, along with the date applications are submitted. The form accommodates up to 20 applicant entries per log and includes fields for tracking applicant names, Social Security numbers, application completion status, and payment authorization status.

The intake site log format allows designated business administrators to verify whether applications are complete and approved for payment processing. Each entry requires documentation of the applicant's Social Security number, full name (last and first), and designation as either complete and ready for payment or incomplete. The form includes a summary section at the bottom for the business administrator to record total amounts to be paid and provide signature authorization with date. This form functions as a critical administrative document for processing EAP assistance payments to eligible low-income and senior populations throughout Nevada seeking support for home energy costs under the Low-Income Home Energy Assistance Program.