Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 14
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38DHS-2
Rev: 01-16
Question 11 (continued)
Non-custodial Parent’s Last Name
First Name
Initial
Sex
Non-custodial Parent’s SSN
Parent’s Birth Date
M [ ] F [ ]
______/____/______
____/____/_____
Non-custodial Parent’s Address
Non-custodial Parent’s Telephone Number
Employer Name
Employer Address
Is this parent disabled and/or a
veteran?
Yes [ ] No [ ]
Were the parents of the child(ren) married to
Are the parents of the child(ren) currently
Non-custodial Parent’s Marital Status
each other? Yes [ ] No [ ]
married to each other? Yes [ ] No [ ]
Never Married [ ] Divorced [ ] Widowed [ ]
If yes, date married _____/_____/______
If no, date divorced _____/_____/______
Married [ ] Separated [ ] Unknown [ ]
Child(ren) of the parent living in this household.
State of Birth
Is child support, health coverage or paternity court ordered?
Child’s Last Name
First
Initial
(If yes, list date.)
1.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
2.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
3.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
4.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
5.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be
harmed by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence
Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us
collect child support:
Non-custodial Parent’s Last Name
First Name
Initial
Sex
Non-Custodial Parent’s SSN
Parent’s Birth Date
M [ ] F [ ]
______/____/______
____/____/_____
Non-custodial Parent’s Address
Non-custodial Parent’s Telephone Number
Employer Name
Employer Address
Is this parent disabled and/or a
veteran? Yes [ ] No [ ]
Were the parents of the child(ren) married to
Are the parents of the child(ren) currently
Non-custodial Parent’s Marital Status
each other? Yes [ ] No [ ]
married to each other? Yes [ ] No [ ]
Never Married [ ] Divorced [ ] Widowed [ ]
If yes, date married _____/_____/______
If no, date divorced _____/_____/______
Married [ ] Separated [ ] Unknown [ ]
Child(ren) of the parent living in this household.
State of Birth
Is child support, health coverage or paternity court ordered?
Child’s Last Name
First
Initial
(If yes, list date.)
1.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
2.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
3.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
4.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
5.
Yes
[ ]
Support
[ ]
Date ________________
No
[ ]
Health Cov
[ ]
Date_________________
Paternity
[ ]
Date_________________
We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be
harmed by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence
Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us
collect child support:
10
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