Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 11
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38DHS-2 Rev. 10-14
Page 7
Yes
Are you, your spouse, or anyone in the household in
4
No
a group living arrangement such as the types listed below?
EXAMPLES
Assisted Living Facility
Shelter for Homeless
Drug Treatment Center
Hospital
Dormitory
Group Home
Alcohol Treatment Center
Shelter for Battered Women
If yes, complete the boxes below about each person.
G R O P
Last Name
First Name
Middle Initial
Name of Facility
Type
Last Name
First Name
Middle Initial
Name of Facility
Type
Are you or anyone in the household who is sixteen (16) or older
5
in high school, college, vocational school or a job-training program? Yes
No
If yes, complete the boxes below about each person.
S C H L
Last Name
First Name
Middle
School/Training Program
Address
Initial
Check
Full
Half
Less than
Date of Completion
Type
Status
Ver
Count
Count
MA
GPA
One
Time
Time
Half Time
RIW
SNAP
[ ]
[ ]
[ ]
Last Name
First Name
Middle
School/Training Program
Address
Initial
Check
Full
Half
Less than
Date of Completion
Type
Status
Ver
Count
Count
MA
GPA
One
Time
Time
Half Time
RIW
SNAP
[ ]
[ ]
[ ]
Besides you or your spouse, is there anyone in the household who Yes
6
No
has children under age twenty-two (22) who also lives in the
household?
If yes, complete the boxes below about each person.
P A R E
Parent’s
Middle
Child’s
Middle
Child’s
Middle
First Name
Initial
First Name
Initial
First Name
Initial
Last Name
Last Name
Last Name
Yes
Is there anyone who lives with you who purchases and prepares
7
No
food separately?
If yes, list the people who do not eat with you.
E A T S
Last Name
First Name Mid dle Initial
Last Name
First Name Mid dle Initial Last Name
First Name Mid dle Initial
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