Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 10
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38DHS-2 Rev. 10-14
Page 6
Are you, your spouse, or anyone in the household a military veteran,
Yes
2
a dependent of a veteran, or a survivor of a veteran?
No
If yes, complete the boxes below about each person.
Middle
Applied for
Date of
Serial
V.A.
Veteran’s Status
Veteran’s Benefits
Claim
Last Name
First Name
Initial
Service
Number
Number
Veteran
[ ]
Yes [ ]
Dependent
[ ]
No [ ]
___/__/___
Survivor
[ ]
Veteran
[ ]
Yes [ ]
Dependent
[ ]
No [ ]
___/__/___
Survivor
[ ]
Veteran
[ ]
Yes [ ]
Dependent
[ ]
No [ ]
___/__/___
Survivor
[ ]
Were you, your spouse, or anyone in the household born outside
3
Yes
the U.S?
No
(If you are applying for Child Care or Katie Beckett, answer this question for the applicant child only.)
**The alien status of applicant household members is subject to verification by USCIS (formerly known as INS) through the
submission of information from this application to USCIS. Submitted information received from USCIS may affect your
household’s eligibility and level of benefits.
If yes, complete the boxes below about each person that is requesting benefits who is not a U.S. citizen.
ALIE
Last Name
First Name
Middle
Country of Origin
Alien Registration
Immigration
Initial
Number
Number
Alien Status:
[ ] Refugee/Granted Aylum
Date of
Entry
USCIS Status Date
[ ] Permanent Resident
Date of
Entry
Permanent Residence Date
[ ] Other
Date of
Entry
USCIS Status Date
Name of Sponsor
Sponsor’s Address
Did this individual reside in the US prior to 8/22/96?
Yes [ ] No [ ]
Last Name
First Name
Middle
Country of Origin
Alien Registration
Immigration
Initial
Number
Number
Alien Status:
[ ] Refugee/Granted Aylum
Date of
Entry
USCIS Status Date
[ ] Permanent Resident
Date of
Entry
Permanent Residence Date
[ ] Other
Date of
Entry
USCIS Status Date
Name of Sponsor
Sponsor’s Address
Did this individual reside in the US prior to 8/22/96?
Yes [ ] No [ ]
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