Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 24
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38DHS-2 Rev. 10-14
Page 20
Do you, your spouse, or anyone in the household receive income
25
Yes
from self-employment?
No
EXAMPLES
Farming
Fishing
Out-of-home day care
Door-to-door sales Home Sales
If yes, complete the boxes below about each person.
B U S I
Last Name
First Name
Middle Initial
Gross Income/How Often
Expenses
Average number of
$
per
$
hours worked per week
Type of Business
Name of Business
Will this income be received in the following
months?
Yes [ ] No [ ]
Please complete the following information about the days and hours spent working at a self-
owned business (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).
Last Name
First Name
Middle Initial
Gross Income/How Often
Expenses
Average number of
$
per
$
hours worked per week
Type of Business
Name of Business
Will this income be received in the following
months?
Yes [ ] No [ ]
Please complete the following information about the days and hours spent working at a self-
owned business (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).
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