Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 12
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38DHS-2 Rev. 10-14
Page 8
8
Are you or anyone in the household pregnant?
Yes
No
If yes, complete the boxes below about the pregnant person.
P R E G
First Name Mid dle Initial Date Baby is Due
Date Baby is Due
Last Name
Last Name
First Name
Mid dle Initial
_ ____/
_/
___
_____/_____/______
Are you, your spouse, or anyone in the household mentally or
Yes
9
disabled or blind?
physically ill, incapacitated,
No
If yes, complete the boxes below about each person.
D I S A
Last Name
First Name
Mid dle Initial
Medical problem (describe)
Caused by an accident?
Yes [ ] No [ ]
Is this person active with the Office of Rehabilitation Services or Services for
Yes [ ]
No [ ]
Factor
Review
the Blind?
Yes [ ]
No [ ]
Has this person applied for SSI or Social Security Benefits (RSDI)?
Ver
Blind
If this person is a parent who is not working, does this person’s disability make
Yes [ ]
No [ ]
him/her unable to care for the child(ren)?
Last Name
First Name
Mid dle Initial
Medical problem (describe)
Caused by an accident?
Yes [ ] No [ ]
Is this person active with the Office of Rehabilitation Services or Services for
Yes [ ]
No [ ]
Factor
Review
the Blind?
Yes [ ]
No [ ]
Has this person applied for SSI or Social Security Benefits (RSDI)?
Ver
Blind
If this person is a parent who is not working, does this person’s disability make
Yes [ ]
No [ ]
him/her unable to care for the child(ren)?
Are there children in the household whose parents are
Yes
10
deceased?
No
If yes, complete the boxes below about each person.
D E C P
Name of Deceased Parent:
Mid dle
Social Security Number
Gender
Date of Birth
Date of Death
Ver
Last Name
First Name
Male
[ ]
Initial
/
/______
Female
[ ]
/
/____
/
/ ____
List the children of this deceased parent in the spaces below.
P
P
P
Last Name
First Name
Mid dle
Last Name
First Name
Mid dle
Last Name
First Name
Mid dle
Initial
Initial
Initial
Last Name
First Name
P
Last Name
First Name
P
Last Name
First Name
P
Mid dle
Mid dle
Mid dle
Initial
Initial
Initial
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