Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services (Page 6 of 38) in pdf

Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 6

DHS-2

Rev: 01-16

HOUSEHOLD COMPOSITION

If you are applying for SNAP, list everyone who lives in your home now, even if they do not want assistance.

If you applying for any other program, only enter the information below for the applicant, his/her, spouse and any dependents. If you are applying for the

Katie Beckett Program, enter the information below for the child only.

Last Name

First Name

D.O.B.

Relationship

S.S.N.

U.S. Citizen?

Answer Yes or No

(Only required if member is

(mm/dd/yyyy)

applying for benefits. If you

(Only required if member is

are applying for child care

applying for benefits. If you are

only, this is needed for the

applying for child care only, this

child(ren))

is needed for the child(ren))

I live in a (Check one):

 01 Elderly/disabled housing

 06 Own home/trailer

 11 Homeless: lobby, street, car

 02 Drug/alcohol rehab center

 07 Rent home/apt/trailer

 12 Residential care and assisted living

 03 Disabled/blind group home  08 Living in another’s home/apt

 13 Long-Term Care Facility

 04 Battered Women’s shelter

 09 No permanent address

 99 Other (specify)________________

 05 Shelter

 10 Halfway house

Yes

Did you move to Rhode Island within the last three (3) months?



No If Yes, Date: ________________

If Yes, what was your reason for moving here?

(check one)

 R

Close to Relatives

 W To get Cash, SNAP/Food Stamps, and/or Medical

L Looking for Employment



 D Domestic Violence

 O

Other________________________(please specify)



Which State did you move from? ________________ Are you receiving assistance from another State?

Yes

If you wish to authorize someone other than yourself to apply on your behalf, please indicate below:

I want ______________________________ to apply on my behalf. __________________________ ____________________

(Name of Individual)

(Daytime Phone #)

(Evening Phone #)

Is anyone who wants assistance pregnant?

Yes

No If yes, Name of person:__________________________ Due Date_______

WITHDRAWAL OF APPLICATION

***FOR AGENCY USE ONLY***



After participating in the screening interview, I do not wish to make an application for

RIW,

SNAP,

Medicaid,

GPA,

CCAP,



MPP,

SSP or

Katie Beckett at this time. I understand that I may apply again at any time. I understand that this application will be

denied and a notice of denial will be sent to me. Please state your reason for withdrawing your application:

_____________________________________________________________

________________________________

Applicant’s Signature

Date

Agency Representative’s Name:

Date Screened

Intake/Interview

Date

Program(s):

Case ID

Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 6

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