Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 26
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38
DHS-2 Rev. 10-14
Page 22
After April 1977, did you ever get an SSI check
28a
at the same time that you got social security, or did you get SSI in
Yes
the month just before social security started?
No
If yes, complete the box below.
Last Name
First Name
Middle Initial
Year Received
*(If you report and provide proof of your expenses you list in 29 -38, it can help you get more benefits from SNAP. If you do not
report an expense or provide proof, then we will assume that you do not want this expense to be counted.)
Do you, your spouse, or anyone in the household
Yes
29
pay for someone to care for children, elderly, or disabled adults due
No
to work, training, looking for work or schooling?
If yes, complete the boxes below about each person who paid for daycare.
D C E X
Name of person paying for care
Day Care is needed because s/he is:
Is this cost
If yes, amount
subsidized
of subsidy?
Working [ ]
In school/ training [ ]
Yes [ ] No [ ]
$
per
Looking for work [ ]
Name of person in care
Adult/Child
Amount of out-of-pocket
Will this cost continue?
Adult [ ]
Payment or co-payment
Yes [ ] No [ ]
Child [ ]
$
per
Name of Day/Adult Care Provider
Address of Provider
Name of person paying for care
Day Care is needed because s/he is:
Is this cost
If yes, amount
subsidized
of subsidy?
Working [ ]
In school/ training [ ]
Yes [ ] No [ ]
$
per
Looking for work [ ]
Name of person in care
Adult/Child
Amount of out-of-pocket
Will this cost continue?
Payment or co-payment
Adult [ ]
Child [ ]
$
per
Yes [ ] No [ ]
Name of Day/Adult Care Provider
Address of Provider
Do you, your spouse, or anyone in the household pay child
30
Yes
support, alimony, or claim as a tax dependent any persons not
No
living in this household?
If yes, complete the boxes below about each person who pays child support, alimony, or claims someone as a tax dependent.
S U P P
Last Name
First Name Middle Initial Who is the person claiming?
Type of claim made:
Amount Paid
Child Support
[ ]
$
How Often?
Alimony
[ ]
[ ]
Other tax dependent
Amount Paid
Last Name
First Name Middle Initial Who is the person claiming?
Type of claim made:
$
[ ]
Child Support
[ ]
How Often?
Alimony
[ ]
Other tax dependent
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