Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 7
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38DHS-2 Rev. 10-14
Page 3
First Name
Middle Initial
Last Name
1a
Have you or has any member of your household been convicted of:
a) a felony under federal or state law for possession, use or distribution of a controlled drug substance (felony drug
conviction) after August 22, 1996? YES NO
b) trading SNAP benefits for drugs after September 22, 1996? YES NO
c) buying or selling SNAP benefits over $500 after September 22, 1996? YES NO
d) fraudulently receiving duplicate SNAP benefits in any state after September 22, 1996? YES NO
e) trading SNAP benefits for guns, ammunitions or explosives after September 22, 1996? YES NO
Are you or any one in your household fleeing to avoid prosecution, custody, or confinement after conviction under the
law of the place from which you are fleeing, for a crime or attempt to commit a crime that is a felony under the law of
the place from which you are fleeing or which, in the case of New Jersey, is a high misdemeanor under the state of New
YES NO
Jersey or violating a condition of probation or parole imposed under a federal or state law?
Have you or anyone in your household ever been found through an Administrative Hearing process of having made,
or been convicted in a Federal or State court of having made, a fraudulent statement or representation with respect to
your identity or place of residence in order to receive multiple Supplemental Nutrition Assistance Program benefits
YES NO
simultaneously?
Have you or any member of your household been barred from participating in the SNAP/Food Stamp Program in another
state? YES NO
1b
The Rhode Island Department of Human Services (DHS) uses an Interactive Voice Response (IVR) system to make
“appointment reminder calls” to remind you of a scheduled phone or office interview appointment. The reminders are
for SNAP and Rhode Island Works certification and recertification appointments. Two days before your scheduled
appointment, the IVR will automatically contact the number you have written on this application, unless you chose to
opt out.
Check here if you would not like to receive information about next steps in the application process from an automated
telephone system:
1c
If you live in a household with a minor child(ren) (under eighteen), is there more than one adult parent or adult
YES NO
who shares parental control/rights over the child(ren)?
If you live in such a household, please designate an adult parent or an adult who has parental control of the child(ren)
as the head of the household here. Name
1d
Have you previously applied for, or received any type of assistance payments, benefits or SNAP/Food
YES NO
Stamp benefits in R.I. or in another state?
If Yes, under what name?
Where?
When?
Type?
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