Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services (Page 3 of 38) in pdf

DHS-2

Rev: 01-16

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, you may leave it blank or contact DHS 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 ASSISTANCE PROGRAM

DOCUMENTS YOU MAY NEED TO

(SNAP)

PROVIDE FOR YOUR INTERVIEW OR

You may file your application immediately as long as we have

SUBMIT FOR BENEFIT APPROVAL

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



Award letters or proof of Social Security, SSI, UCB, TDI, Worker’s

calculated from the date we receive this form in our office.

Compensation, etc.



Bank statements for checking accounts, savings accounts,

We are required to verify information you provide and take

certificates of deposit, credit union accounts, or stocks and bonds

action on your application within thirty (30) days of the



Birth Certificate for all household members

filing date unless you are entitled to expedited service. To



Child care receipts

determine whether or not you are eligible, you must be



Copy of child support orders, proof of child support and/or

interviewed. The application filing date for pre-release

alimony payments, divorce decree, marriage license

applicants is the date of release from the institution.



Death certificate of deceased parent for any dependent child for

whom you may be applying or for any deceased Medicaid

You will be sent a written request for any verification

applicant

missing from your application. Your application will be



Deeds for any home or property

denied if the missing verification is not received within ten



Proof of identity (driver’s license, rent receipt, etc.)

(10) days of the written request.

If not a U.S. Citizen, proof of Immigration status



Proof of income from rental property

FINANCIAL ASSISTANCE (RIW) (GPA) (CCAP)(SSP)



Proof of medical expenses such as: medications, hospital bills,

If you are applying for RIW GPA, CCAP or SSP and are

doctor bills, or insurance premiums

determined eligible for benefits, those benefits will be



Proof of health and or dental insurance coverage and premium

determined from the date the signed application is received.

amount paid

MEDICAID



Life insurance policies and Burial contracts

Medical benefits for adults may be provided for up to t hree



Passport or Certificate of Naturalization or other documentation

application is received provided all factors of eligibility are

to prove Citizenship and Identity



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

If you try and are unable to obtain any of the above,

Instructions Page 3 of 4

the Agency may assist any cooperating households.

Form Dhs-2 - Application For Assistance - Rhode Island Department Of Human Services Page 3

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