Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 6
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38DHS-2 Rev. 10-14
Page 2
HOUSEHOLD COMPOSITION
If you are applying for SNAP, list everyone who lives in your home now, even if they do not want assistance.
If you applying for any other program, only enter the information below for the applicant, his/her, spouse and any dependents. If you are applying for
the Katie Beckett Program, enter the information below for the child only.
Last Name
First Name
D.O.B.
Relationship
S.S.N.
U.S. Citizen?
(Only required if member is
Answer Yes or No
(mm/dd/yyyy)
applying for benefits. If you
(Only required if member is
are applying for child care
applying for benefits. If you are
only, this is needed for the
applying for child care only,
child(ren))
this is needed for the
I live in a (Check one):
01 Elderly/disabled housing
06 Own home/trailer
11 Homeless: lobby, street, car
02 Drug/alcohol rehab center
07 Rent home/apt/trailer
12 Residential care and assisted living
03 Disabled/blind group home
08 Living in another’s home/apt
13 Long-Term Care Facility
04 Battered Women’s shelter
09 No permanent address
99 Other (specify)
05 Shelter
10 Halfway house
Yes
No If Yes, Date:
Did you move to Rhode Island within the last three (3)
months? If Yes, what was your reason for moving here?
(check one)
Close to Relatives
To get Cash, SNAP/Food Stamps, and/or Medical
Looking for Employment
Domestic Violence
Other
(please specify)
Which State did you move from?
Are you receiving assistance from another State?
Yes
No
Information for SNAP applicants:
You may file your application immediately as long as we have your name, address and the signature of a responsible household member or your
authorized representative on this application. If you are determined eligible, benefits will be calculated from the date we receive this form in our
office. We are required to verify information you provide and take action on your application within thirty (30) days of the filing date unless you
are entitled to expedited service. To determine whether or not you are eligible, you must be interviewed. The application filing date for pre-
release applicants is the date of release from the institution.
Under penalty of perjury, I attest that all of the information contained in this application is true. I understand that I am
breaking the law if I give wrong information and can be punished under federal law, state law or both.
Signature of Applicant or Recipient
Date
Signature of Authorized Representative
Date
Signature of Guardian, Conservator or Holder of Power of
Signature of Spouse or other parent of child(ren)
Date
Date
Attorney
WITHDRAWAL OF APPLICATION
***FOR AGENCY USE ONLY***
After participating in the screening interview, I do not wish to make an application for
RIW,
SNAP,
Medicaid,
GPA,
CCAP,
MPP,
SSP or
Katie Beckett at this time. I understand that I may apply again at any time. I understand that this application will be
denied and a notice of denial will be sent to me. Please state your reason for withdrawing your application: __________________________
_________________________________________________________________________________________________________________
Applicant’s Signature
Date
Intake/Interview
Agency Representative’s Name:
Date Screened
Date
Program(s):
Case ID
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