Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 28
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38DHS-2
Rev:01-16
Do you, your spouse, or anyone in the household pay all, or a share
33a
Yes
of, the fuel or utilities?
No
If yes, complete the boxes below about each person who pays a utility cost.
U T I L
Last Name
First Name
Initial
Utility
Amount Paid/How Often
Used to Heat/Cool
Oil
$_________per_________
Heat [ ] Cool [ ]
Gas
$_________per_________
Heat [ ] Cool [ ]
Wood or Coal
$_________per_________
Heat [ ] Cool [ ]
Electric
$_________per_________
Heat [ ] Cool [ ]
Telephone
$_________per_________
Water
$_________per_________
Sewer
$_________per_________
Rubbish Removal
$_________per_________
Other
$_________per_________
Does anyone share the heating or cooling costs in your home? Yes [ ]
No [ ]
If yes, name of the person(s) sharing the heating or cooling costs___________________________________________
What is the amount of the heating/cooling costs this person pays? $________________________________
Do you, your spouse, or anyone in the household pay for room
Yes
34
No
and/or board?
If yes, complete the boxes below about each person who pays room and/or board.
R B E X
Last Name
First Name
Initial
Amount Paid/How Often
What does the room/board cover?
$_______________
Room only [ ] Board(1-2 meals) [ ] Board(3meals) [ ]
per_____________
Is there anyone in the household who is age sixty (60) or older
35
Yes
or disabled, who incurs any medical expenses not covered by health
No
insurance?
EXAMPLES:
Health insurance premiums
Hearing aids
Dental care
Prescription Drugs
Medicare premiums
Eyeglasses
Transportation to medical treatment or services
If yes, complete the boxes below about each person who has medical expenses.
F M E D
Last Name
First Name
Initial
Type of medical expense
Amount Incurred
When do you
$______________
expect this to end?
How Often? _____________
Last Name
First Name
Initial
Type of medical expense
Amount Incurred
When do you
$______________
expect this to end?
How Often? _____________
Last Name
First Name
Initial
Type of medical expense
Amount Incurred
When do you
$______________
expect this to end?
How Often? _____________
Are you, your spouse, or anyone in the household covered by
36
Yes
Medicare?
No
If yes, complete the boxes below about each person.
M E D I
Last Name
First Name
Initial
Medicare Claim Number
MPP
QDWI
___________-___________-___________
Part A begin date (month/day/year)
Part A Premium
Who pays this expense?
P A Y O R
$
Part B begin date (month/day/year)
Part B Premium
Who pays this expense?
PAYOR
BUY
IN
$
24
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