Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 18
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38DHS-2 Rev. 10-14
Page 14
Do you, your spouse, or anyone in the household own any items
Yes
17
of value?
No
(Include any items of value not listed in questions 14, 15 or 16)
EXAMPLES:
Stocks
Personal Property (antiques, collections, jewelry, etc.)
Burial Contract
Bonds
Life Insurance
Reverse Mortgages
Long-term Care Insurance
If yes, complete the boxes below.
R E S O
STOCKS, BONDS, OTHER
Last Name
First Name
Middle Initial
Type of Resource
Co-owner’s Last Name
First Name
Middle Initial
Co-owner’s Address
Last Name
First Name
Type of Resource
Middle Initial
Co-owner’s Last Name
First Name
Middle Initial
Co-owner’s Address
Last Name
First Name
Middle Initial
Type of Resource
Co-owner’s Last Name
First Name
Middle Initial
Co-owner’s Address
LIFE INSURANCE/LONG-TERM CARE INSURANCE
Last Name
First Name Middle Initial
Company Name
Policy Number
Type
Owned By
Face Value
Cash Value
Loan Amount
Last Name
First Name Middle Initial
Company Name
Policy Number
Type
Owned By
Face Value
Cash Value
Loan Amount
Last Name
First Name Middle Initial
Company Name
Policy Number
Type
Owned By
Face Value
Cash Value
Loan Amount
BURIAL CONTRACT
Last Name
First Name
Initial
Value
Irrevocable
Effective Date
/
/
Funeral Home
Funeral Home Address
Last Name
First Name
Initial
Value
Irrevocable
Effective Date
/
/
Funeral Home
Funeral Home Address
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Parent category: Legal