Response

Nevada Treasury
Student Loan Ombudsman Program
1 State of Nevada Way, 4th Floor
Las Vegas, NV 89119
(702) 486-3384

Client Intake Form

Contact Information

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

City

State

Zip

Phone

Preferred method of contact

Please provide your questions or describe in detail your concerns or complaints about your student loans. (short answer)

Demographic Information (Optional)

What is the highest level of education you have completed?

What is your current employment status?

What is your current annual household income?

What is your household size?

How do you identify?

Male
Female
Prefer not to stay

What are your preferred pronouns?

She, Her, Hers
He, Him, His
Other

Other

Are you Hispanic, Latino or of Spanish origin?

Yes
No
Prefer not to say

Any documentation related to your situation

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By signing this form and using the Student Loan Ombudsman program, you acknowledge that any information you submit on this form may become public record subject to NRS Chapter 239.

By signing this form, you acknowledge that you are granting the Office permission to use your submitted information to make inquiries into your records on your behalf to attempt to facilitate the resolution of your concern. You further acknowledge that the Office cannot act as your legal counsel, and the Office disclaims any and all liability in relation to the Office's attempts to assist you as an ombudsman.

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