Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 27
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Yes
No
Yes
No
____________________________________
____________________________________
If yes, name of person:
____________________________________
___________________________________
Does anyone share the cost of this expense?
___________________________________
of
Yes [ ] No [ ]
____________________________________
Does anyone share the cost of this expense?
___________________________________
of
___________________________________
Yes [ ] No [ ]
___________________________________
Does anyone share the cost of this expense?
Yes [ ] No [ ] Name
___________________________________
___________________________________
Does anyone share the cost of this expense?
___________________________________
Yes [ ] No [ ]
Does anyone share the cost of this expense?
____________________________________
____________________________________
Yes [ ] No [ ]
Yes
No
2
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