Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 5
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38DHS-2 Rev. 10-14
Page 1
RHODE ISLAND DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR ASSISTANCE
Do you speak English?
Yes
No
If No, what is the primary language spoken?
Can you read and write in English?
Yes
No
Do you need an Interpreter?
Yes
No
If you do not speak English, does any adult member of the household speak English?
Yes
No
I want to apply for:
CASH ASSISTANCE (RHODE ISLAND WORKS PROGRAM- RIW)
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
MEDICAID: LONG-TERM SERVICES AND SUPPORTS
MEDICAID/HEALTH COVERAGEFORAGE 65 AND OVER, BLIND OR
DISABLED ANORRKING ADULTS WITH DISABILITIES (SHERLOCK PLAN)
GENERAL PUBLIC ASSISTANCE (GPA)
CHILD CARE ASSISTANCE PROGRAM (CCAP)
MEDICARE PREMIUM PAYMENT PROGRAM (MPP)
RI SSI STATE SUPPLEMENTAL PAYMENT PROGRAM (SSP)
KATIE BECKETT: MEDICAID/HEALTH COVERAGE FOR CHILDREN WITH
SEVERE DISABILITIES
First Name
M.I.
Last Name
Maiden Name
Social Security #
-
-
Date of Birth
/
/
MARITAL STATUS:
Single
Married
Divorced
Other
GENDER:
Male
Female
Residence Address
Street/Route
Apt./Floor
City
State
Zip
Mailing Address
(if different)
Street/Route
Apt./Floor
PO Box
City/Town
State
Zip
If you are applying for SNAP benefits, how would you like to be interviewed? Check one of the boxes:
Telephone Interview (DHS will call you) (OR) In-Office Interview
Telephone Number: Day
Evening
If you wish to authorize someone other than yourself to apply on your behalf, please indicate below:
I want
to apply on my behalf.
(Name of Individual)
(Daytime Phone #)
(Evening Phone #)
Is anyone who wants assistance pregnant? Yes No
If Yes, Name of Person:
Due Date:
YOU MAY GET SNAP BENEFITS, IF ELIGIBLE, WITHIN 7 DAYS IF: your income, cash and money in the bank add up to less than
your monthly housing expense; or your monthly income is less than $150 and your money in the bank and liquid resources are less than $100; or
you are a migrant or seasonal farm worker.
a. How much money do members of your household have in cash or money in the bank? $
b. What is the total amount of income from any source (including unearned income such as Child Support, SSI,
TDI, Unemployment, or SSDI, etc.) you expect your household to receive this month? $
c. What is your current monthly rent/mortgage payment? $
Utilities?
$
d. Is anyone in your household a migrant or seasonal farm worker?
Yes
No
Applicant’s Signature
Date
**
You may tear off this sheet and submit JUST the front and backside of this page with Name Address and Signature to allow us to date stamp and
initiate this application. To determine ongoing benefit eligibility, you must sign and complete the remainder of this application.
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