Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 25
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38DHS-2 Rev. 10-14
Page 21
Yes
Are you under 20 and do not have a high school diploma or
26
No
GED?
27
Do you, your spouse, or anyone in the household receive a
Yes
student grant, scholarship, educational loan or VA educational
No
benefits?
If yes, complete the boxes below using separate lines for each source. Please bring verification for all tuition and fees.
S T I N
Last Name
First Name
Middle Initial
Amount received
Period covered by grant/loan
Date received
$
From
to
/
/
_
Type of Grant/Loan
Date of last payment
Will this income be received in the
/
/
following months? Yes [ ] No [ ]
Do you, or your spouse, or anyone in the household receive or expect to
28
Yes
receive, income such as the type below?
No
EXAMPLES:
Adoption Subsidy
Gifts, Prizes, Inheritance, Lottery
Promissory Note
Trust Funds
Alien Sponsorship
In-kind Shelter
Railroad Retirement
Unemployment Compensation
Annuities
Income Tax Refund
Retirement Pensions
VA Aid and Attendance
Alimony
Insurance and Lawsuit Claim
Section & Utility Payment
VA Basic Benefits
Child Support
IRA Distributions
Social Security (RSDI)
VA Compensation
Dividends, Interest
Military Allotment
SSI
VA Improved Pension
Worker’s Compensation
Earned Income Tax Credit Refund
Other in-kind
Strike Benefits
Foster Care
Out of State Assistance
TDI
If yes, complete the boxes below for each type of income that person receives.
U N E A
Last Name
First Name
Middle Initial
Amount/How Often
Date Income Received
$ ___________per__________
______/______/______
Claim Number (if applicable)
Type of Income
Will this income be received in the following months?
Yes [ ] No [ ]
Last Name
First Name
Middle Initial
Amount/How Often
Date Income Received
$ ___________per__________
______/______/______
Claim Number (if applicable)
Type of Income
Will this income be received in the following months?
Yes [ ] No [ ]
Last Name
First Name
Middle Initial
Amount/How Often
Date Income Received
$ ___________per__________
______/______/______
Claim Number (if applicable)
Type of Income
Will this income be received in the following months?
Yes [ ] No [ ]
Last Name
First Name
Middle Initial
Amount/How Often
Date Income Received
$ ___________per__________
______/______/______
Claim Number (if applicable)
Type of Income
Will this income be received in the following months?
Yes [ ] No [ ]
If anyone in the household expects income in the future, fill in the box below for that person.
Last Name
First Name
Middle Initial
Type of income Expected
Expected Date income will be
received
______/______/______
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