Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 22
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38DHS-2 Rev. 10-14
Page 18
Question 20 (Continued)
Last Name
First Name
Middle Initial
Employer Name and Address
Date Job Began/Will Begin
Type of Work
Day of Week Paid
/
/
How Often Paid:
Weekly
Every two weeks
Twice a month
Monthly
Other
List the gross mount paid on each pay day this month.
Pay Day
Date Paid
Pay period end date
Hours worked per pay
Gross wages before
Tips/Commissions
period
taxes
1 st
$
$
2 nd
$
$
$
$
3 rd
4 th
$
$
Did you receive earned income tax credit in your paycheck?
Yes
No
Is this job part of a work study program?
Yes
No
Is this an On the Job training program?
Yes
No
Will this income be received in the following month?
Yes
No
List the number of hours you expect to be paid for next month:
Number of Hours:
Expected Gross Earnings:$
Tips/Commissions: $
Work/School/Training Schedule (Child Care only)
Day
Start Time
End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
If your schedule varies, please explain how (you may send additional documentation to verify).
Do you, your spouse, or anyone in the household have an outstanding claim
21
or lawsuit for injuries or illness sustained due to an automobile
Yes
accident, workers’ compensation claim, etc, or for any lawsuit in
No
which you may receive money?
If yes, complete the boxes below.
S E T T
Workers’
Last Name
First Name
Middle Initial
Type of Claim (describe)
Date of Incident
/
/
Compensation
Yes [ ]
No [ ]
Person (or company) responsible
Insurance Company
Attorney Name
Address
Address
Address
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