Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 28
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38DHS-2 Rev. 10-14
Page 24
Do you, your spouse, or anyone in the household pay all, or a share
Yes
33a
No
of the fuel or utilities?
If yes, complete the boxes below about each person who pays a utility cost.
U T I L
Last Name
First Name
Middle Initial
Utility
Amount Paid/How Often
Used to Heat/Cool
Oil
$
per
Heat [ ] Cool [ ]
Gas
$
per
Heat [ ] Cool [ ]
Wood or Coal
$
per
Heat [ ] Cool [ ]
Electric
$
per
Heat [ ] Cool [ ]
Telephone
$
per
Water
$
per
Sewer
$
per
Rubbish Removal
$
per
Other
$
per
Does anyone share the heating or cooling costs in your home? Yes [ ]
No [ ]
If yes, name of the person(s) sharing the heating or cooling costs
What is the amount of the heating/cooling costs this person pays? $
Yes
Do you, your spouse, or anyone in the household pay for room
34
No
and/or board?
If yes, complete the boxes below about each person who pays room and/or board.
R B E X
Last Name
First Name
Middle Initial
Amount Paid/How Often
What does the room/board cover?
$
per_
Room only [ ] Board (1-2 meals) [ ] Board (3 meals) [ ]
Is there anyone in the household who is age sixty (60) or older
Yes
35
or disabled, who incurs any medical expenses not covered by health
No
insurance?
EXAMPLES:
Health insurance premiums
Hearing aids
Dental care
Prescription Drugs
Medicare premiums
Eyeglasses
Transportation to medical treatment or services
If yes, complete the boxes below about each person who has medical expenses.
F M E D
Last Name
First Name
Middle Initial
Type of medical expense
Amount Incurred
When do you
$
expect this to end?
How Often?
Last Name
First Name
Middle Initial
Type of medical expense
Amount Incurred
When do you
$
expect this to end?
How Often?
Last Name
First Name
Middle Initial Type of medical expense
Amount Incurred
When do you
$
expect this to end?
How Often?
Are you, your spouse, or anyone in the household covered by
Yes
36
No
Medicare?
If yes, complete the boxes below about each person.
M E D I
Last Name
First Name
Middle Initial
Medicare Claim Number
-
-
Part A begin date (month/day/year)
Part A Premium
Who pays this expense?
$
Part B begin date (month/day/year)
Part B Premium
Who pays this expense?
$
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