Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 19
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38DHS-2 Rev. 10-14
Page 15
Do you, your spouse, or anyone in the household own any
18
Yes
No
interest in any property such as land, buildings, life estate,
timeshare, etc?
(Unless you are applying for LTSS, do not report the home in which you live)
If yes, complete the boxes below about each person.
P R O P
Owner’s Last Name
First Name
Middle Initial Type of property (describe)
Cash Value
Amount Owed
$
$
How is the property owned?
Address of Property
Solely Jointly Life Estate
Other
Is this property your home? Yes No The home of your spouse? Yes No Your dependents? Yes No
Have you, your spouse, or anyone in the household given away,
Yes
19
sold, deeded, or transferred to anyone or any entity, any items of
No
value in the past sixty (60) months?
If you are applying for SNAP benefits only and asked to answer this question, report the items of value that were transferred
within the last three (3) months.
If yes, complete the boxes below.
T R A N
Last Name
First Name
Middle Initial
Resource Transferred
Amount Transferred
Date Transferred
What did you receive in return?
$_________________
______/______/______
Last Name
First Name
Middle Initial
Resource Transferred
Amount Transferred
Date Transferred
What did you receive in return?
$_________________
______/______/______
Last Name
First Name
Middle Initial
Resource Transferred
Amount Transferred
Date Transferred
What did you receive in return?
$_________________
______/______/______
Are you named as a beneficiary (primary, secondary, etc.) on
19a
No
any trust?
If yes, you must provide copies of the trust even if you are not currently receiving any payments from the trust.
Principal amount and date established
Amount of payments to you
Frequency of payments to you
$
Date
/_
/
$
Yes
Have you, your spouse, or anyone acting on your behalf
19b
(including a court) established a trust or put any money or other
No
resource into a trust within the last sixty (60) months?
Yes
Has any property come out of a trust within the last sixty (60) months?
No
If yes, you must provide copies of the trust and describe all such transactions into or out of the trust.
Established by
Date established
Amount
/
/
$
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