Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 14
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38DHS-2 Rev. 10-14
Page 10
Question 11 (continued)
Non-custodial Parent’s Last Name
Non-custodial Parent’s SSN
Parent’s Birth Date
First Name Middle Initial
Sex
M [ ] F [ ]
_____/____/_____
_____/____/_____
Non-custodial Parent’s Address
Non-custodial Parent’s Telephone Number
Employer Name
Employer Address
Is this parent disabled and/or a
veteran?
Yes [ ] No [ ]
Non-custodial Parent’s Marital Status Never
Were the parents of the child(ren) married to
Are the parents of the child(ren) currently
each other? Yes [ ] No [ ]
married to each other? Yes [ ] No [ ]
Married [ ] Divorced [ ] Widowed [ ]
If yes, date married
/
/
If no, date divorced
/
/
Married [ ] Separated [ ] Unknown [ ]
Child(ren) of the parent living in this household.
State of Birth
Is child support, health coverage or paternity court ordered?
Child’s Last Name
First
Middle Initial
(If yes, list date.)
1.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
2.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
3.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
4.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
5.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be harmed by the
non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence Advocate who can
discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us collect child support:
Non-custodial Parent’s Last Name
Non-Custodial Parent’s SSN
Parent’s Birth Date
First Name
Middle Initial
Sex
M [ ] F [ ]
_____/____/_____
_____/____/_____
Non-custodial Parent’s Address
Non-custodial Parent’s Telephone Number
Employer Name
Employer Address
Is this parent disabled and/or a
veteran? Yes [ ] No [ ]
Non-custodial Parent’s Marital Status Never
Were the parents of the child(ren) married to
Are the parents of the child(ren) currently
each other? Yes [ ] No [ ]
married to each other? Yes [ ] No [ ]
Married [ ] Divorced [ ] Widowed [ ]
If no, date divorced
/
/
If yes, date married
/
/
Married [ ] Separated [ ] Unknown [ ]
Child(ren) of the parent living in this household.
State of Birth
Is child support, health coverage or paternity court ordered?
Child’s Last Name
First
Middle Initial
(If yes, list date.)
1.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
2.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
3.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
4.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
5.
Yes
[ ]
Support
[ ]
Date
No
[ ]
Health Cov
[ ]
Date
Paternity
[ ]
Date
We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be harmed by the
non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic Violence Advocate who can
discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child if you help us collect child support:
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