Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 3
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38DHS-2 Rev. 10-14
Instructions Page 3 of 4
This document should be filled out by you or an adult member of your household, or a relative, friend or authorized representative
who knows the financial situation of all household members.
On the following pages list all members of your household. If you answer “Yes” to a question, your answers must be
complete, clear and correct before your application will be processed. If they are not, additional information may be
requested. If you do not understand a question, please call for assistance. If you need more space to report information, use
page 26 titled, “For Client Use Only”.
ELECTRONIC BENEFIT TRANSER (EBT) CARD
RIW cash assistance and SNAP benefits are issued through the Electronic Benefit Transfer (EBT) process. You can get your
benefits by using your EBT card. You will receive more information about this process from your local office.
SUPPLEMENTAL NUTRITION
DOCUMENTS YOU MAY NEED TO
ASSISTANCE PROGRAM (SNAP)
PROVIDE FOR YOUR INTERVIEW
OR SUBMIT FOR BENEFIT
Your SNAP application will be considered from the
APPROVAL
date the signed form is received. If you are found
eligible for SNAP benefits, those benefits will be
• Award letters or proof of Social Security, SSI, UCB, TDI,
determined from the date your signed application is
Worker’s Compensation, etc.
received by the agency. You will be sent a written
•
Bank statements for checking accounts, savings accounts,
request for any verification missing from your
certificates of deposit, credit union accounts, or stocks and bonds
•
Birth Certificate for all household members
application. Your application will be denied if the
•
Child care receipts
missing verification is not received within ten (10)
•
Copy of child support orders, proof of child support and/or
days of the written request.
alimony payments, divorce decree, marriage license
•
FINANCIAL ASSISTANCE (RIW) (GPA)
Death certificate of deceased parent for any dependent child for
(CCAP)(SSP)
whom you may be applying or for any deceased Medicaid
applicant
•
Deeds for any home or property
If you are applying for RIW GPA, CCAP or SSP
•
Proof of identity (driver’s license, rent receipt, etc.)
and are determined eligible for benefits, those
If not a U.S. Citizen, proof of Immigration status
benefits will be determined from the date the
•
Proof of income from rental property
signed application is received.
•
Proof of medical expenses such as: medications, hospital bills,
doctor bills, or insurance premiums
MEDICAID
•
Proof of health and or dental insurance coverage and premium
amount paid
Medical benefits for adults may be provided for up to
•
Life insurance policies and Burial contracts
three (3) months prior to the month in which the signed
•
Passport or Certificate of Naturalization or other documentation
application is received provided all factors of eligibility
to prove Citizenship and Identity
are met for each month.
•
Pay stubs, pay envelopes, earnings statement and/or proof of last
date worked and last pay
•
Pensions and any other unearned income
•
Proof of pregnancy, if pregnant
•
Copy of Power of Attorney or guardianship
•
Public Assistance/MA/SNAP closing notice from another state
•
Rent receipt/mortgage payment (including home insurance,
taxes, and other shelter expenses)
•
Self-employed persons: Federal tax return, bookkeeping records,
or sales and expenditures records
•
Social Security numbers for all household members and absent
parents
•
Trust documents, complete annuity contract and promissory
DO NOT WRITE IN
WRITE IN YELLOW
notes
•
BLUE SHADED AREAS
SHADED AREAS ONLY
Utility receipts
•
Vehicle registration (s)
•
Veteran’s claim number
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