RHODE ISLAND DEPARTMENT OF HUMAN SERVICES

DHS-2 Rev. 09-16

Instructions Page

of 4

APPLICATION FOR ASSISTANCE (DHS-2)

Getting Help with this Application

You can ask for help in completing this form. You can ask for the form and notices to be translated. If you have

a disability or condition that makes it hard for you to understand or answer questions on this application, we can

help. Please let us know by speaking with a DHS representative or calling the DHS Call Center at

1-855-MYRIDHS (1-855-697-4347).

Who Should Complete the Application?

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.

Answering the Questions

If you answer all the questions on the assistance application, we can determine if you are eligible for ALL

programs. Instruction pages 3 and 4 provide a description of each program that you can apply for using this

application. Small boxes with the program acronyms/initials will appear next to each of the questions on the

application. These boxes with the acronyms/initials tell you which questions you must answer for each program.

For example, if you are applying for child care assistance, answer those questions that have CCAP next to them.

If you are applying for SNAP only, although we encourage you to fill out as much of the application as possible,

we will accept your application if it is submitted with just a name, address and signature.

Each question is followed by a section of boxes used for filling in the required information. Respond to each

question by indicating either YES or NO with a check mark in the box next to the question. IF the answer is YES

supply the requested information by writing in the space available beneath the question. You must provide the

information asked for EVERY household member. If the question does not apply to you or anyone in your

household, then the answer is NO. Leave the box blank and move on to the next question.

Securing your Application Date

The first page of this application can be detached and submitted with your signature to DHS to establish a start

date and begin your application. You will need to complete and submit the rest of the application in order to

receive benefits/coverage.

If you need more space to answer questions

Turn to page 27 if you run out of space where there are boxes to write in additional information. Indicate

in one of the boxes which

question you are referring with its number. You may also attach separate sheets

of paper, if necessary.

Your Rights and Responsibilities/Signature Page

Read pages 28-32

. These pages contain important information about your Rights and Responsibilities. All

applicants are required to sign application page 32 before submitting the application. If you submit the first

page only to secure your application date, you must sign application page 1 and then submit the rest of the

application with a signature on application page 32.

Appointing an Authorized Representative

If you would like to appoint an authorized representative to act on behalf of the household in applying for

program benefits or using the benefits you may do so on application page 2.

Electronic Benefit Transfer (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.

Application Mailing Address: RI Department of Human Services, P.O. Box 8709, Cranston, RI 02920-8787

General Instructions for Completing this Application

DHS-2 Rev. 09-16

Instructions Page

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EXAMPLES OF DOCUMENTS YOU MAY NEED TO PROVIDE FOR YOUR INTERVIEW

OR TO SUBMIT FOR BENEFIT APPROVAL

Note: The same document may be used to verify more than one category, for example, a driver’s license can verify identity and address. If you

are applying for Medicaid, we will verify your information with data sources as much as possible.

1. To verify your identity, age/date of birth, citizenship and/or immigration status (All Programs)

 Driver’s License

 School or work Idenﬁcaon

 Immigraon and Naturalizaon Documents (e.g., Green Card)



Hospital birth records

 Birth Cerﬁcates

 U.S. Passport

 Any other documentaon requested for cizenship, immigraon

status, or age may be used for veriﬁcaon of identy

2. To verify your Rhode Island residence (All Programs except ACC, unless questionable)

 Rent or mortgage receipts showing address

 Lease agreement of leer from landlord

 Library card showing address

 Mail received with your home address (ulity bills, bank statements)



Voter’s registraon card

3. To verify your income (All Programs)

 Check stubs (showing the last 30 days of income)

 Proof of alimony received



Employer statement showing income before taxes, hourly work schedule

and the number of hours worked for the past four weeks (if you get paid in

cash or you do not have your check stubs)



Proof of receipt of unemployment insurance beneﬁts, temporary

disability beneﬁts (TDI), Veteran’s Administraon (VA) beneﬁts.



Previous tax returns

 Social Security, Supplemental Security Income, or Veteran’s Beneﬁts

award leer

 Proof of self-employment income (includes rental income and freelance

work): provide tax returns or self-employment ledger

 Other rerement or disability beneﬁt award leers

 Child Support court order

4. To verify your resources (RIW, GPA, EAD, LTSS, MPP, SSP, KB, CCAP if over $9,500)



Documentaon of ownership of a trust

 Vehicle registration including car, boat, truck, motorcycle, camper



Proof of rental properes

 Proof of ownership of other income producing property



Trust documents, property

 Proof of ownership of a burial plot (if you own more than one)



Stock and/or bonds

 Bank accounts, savings accounts, credit union statements, CD’s



Proof of ownership of real property other than your home.

5. To verify your dependent care expenses (RIW, SNAP)

 Proof of expenses related to child care or caring for incapacitated adult living in the home: receipts showing your out-of-pocket expenses

6. To verify your shelter costs (SNAP, RIW, LTSS)

 Rent, lease or mortgage documents

 Proof of property insurance



Statement from landlord

 Receipts or statement from ulity company

 Property taxes statement

 Statement from person who shares shelter costs



Statement from U.S. Department of Housing and Urban Development (HUD)

7. To verify your child support expenses (SNAP, ACC)

 Child support that you pay: income summary if child support is deducted from wages or income

 Copy of court order

8. To verify your medical expenses not covered by insurance (SNAP, EAD)

 Summary of provided services such as doctor or hospital visits

 Prescription pill bottles showing cost on label or printout

 Receipts showing unreimbursed medical expenses

 Invoices or receipts for medical equipment (including the rental cost)

 Health insurance policy showing premium amount

9. To verify relationships among household members (RIW, CCAP, ACC)

 Adoption papers or records

 Marriage license/tribal marriage certificates

 Hospital or public health records of birth or parentage

 Divorce/custody papers



Child support paternity records



Guardianship papers or records

10. To verify your disability or blindness (RIW, SNAP, CCAP, GPA, EAD, LTSS)



Proof of receipt of Rerement, Survivors, and Disability Insurance (RSDI) or Supplemental Security Income (SSI); copy of the award leer or similar

documentaon from the Social Security Administraon and/or current ﬁnding of eligibility for RSDI or SSI based on blindness



Copy of medical examinaon report on ﬁle at the Oﬃce of Rehabilitaon Services (ORS), Services for the Blind and Visually Impaired

 Statement from a medical professional

DHS-2 Rev. 09-16

Instructions Page

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ABOUT THE PROGRAMS

gain, the letter boxes next to each program below are used through this application to identify questions you need to answer to be

considered for specific programs. Answer only those questions for the programs you want to apply for. For example, if you want to

apply for all programs, answer all the questions. If you are applying for only RIW and ACC, you must answer a question with a RIW or

ACC box above it, and can leave the other questions blank.

RIW RI Works (RIW) Cash Assistance: The RIW Program gives cash assistance for a limited number of months to families in need of

support, as well as those who are unable to work, or in training or looking for a job. Applicants for RIW must be responsible for the support and

care of a child under age 18, or between ages 18 and 19 if enrolled full-time in and expected to complete secondary school prior to their 19th

birthday. A pregnant woman with no other children can qualify for assistance if she is in her third trimester of pregnancy. RIW requires

an interview with an eligibility worker and a meeting with a Social Caseworker to complete an employment plan.

SNAP Supplemental Nutrition Assistance Program (SNAP): SNAP, formerly known as food stamps, helps low income households buy

the food needed to stay healthy. Your income minus certain allowable expenses will determine if you are eligible for SNAP benefits. You will

need to participate in an interview over the telephone or in the office before you can be granted SNAP benefits.

CCAP Child Care Assistance Program (CCAP): Child Care Assistance is available to families with earnings up to 180% of the federal

poverty level and is only available to cover hours of employment or short-term training. Families may be required to pay a co-payment based on

their family size, income level and number of children. Families that participate in RIW automatically meet the income requirements for CCAP.

Prior to enrollment, RIW applicants or participants who are not employed must discuss child care options with a Social Worker as part of the

assessment process and the development of the employment plan. For families not participating in the RIW Program, eligibility for CCAP is

based on working at least 20 hours per week at or above Rhode Island's minimum wage.

GPA General Public Assistance (GPA) Program: GPA is available for adults ages 18-64 who have very limited income and resources

and have a chronic or disabling illness or condition that keeps them from working. Adults who have a current pending application for

Supplemental Security Income (SSI) may be determined eligible for GPA benefits. A determination for ACC Medicaid health care coverage must

be completed prior to a determination of eligibility based on a disabling condition. GPA applicants can apply for ACC Medicaid healthcare

coverage by completing the ACC questions on this application, or by applying online at www.healthyrhode.ri.gov.

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM

(SNAP)

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.

You will be sent a written request for any verification missing from your application. Your application will be denied if the

missing verification is not received within ten (10) days of the written request.

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

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

determined eligible for benefits, those benefits will be

determined from

the date the signed application is

received.

MEDICAID (LTSS) (EAD)

Retroactive Medicaid coverage for certain health expenses may be provided to applicants eligible through the LTSS and EAD pathways for up

to three (3) months prior to the date we receive a signed

application, provided all factors of eligibility are

met for each month. There is no

retroactive coverage available for ACC Medicaid beneficiaries.

Applicants may qualify for Medicaid through more than one eligibility pathway. If you are uncertain which pathway best suits the needs of

the applicants in your household, contact 1-855-MYRIDHS (1-855-697-4347).

DHS-2 Rev. 09-16

Instructions Page

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SSP RI SSI State Supplemental Payment Program (SSP): The State of Rhode Island supplements the Federal Supplemental Security

Income (SSI) benefit rate for eligible persons. Authorization of the monthly SSP for current SSI recipients will be completed automatically when

they apply at SSA. Applicants for SSP who have been denied through SSA for excess income will need to meet the income, resource, age

and/or disability standards (age 65 or older, disabled or blind) established for Medicaid for low-income persons who are aged or living with a

disability. If an applicant is eligible based on income and is claiming a disability which has not been reviewed or determined by the SSA, the

SSP Unit will send a referral to the Medicaid Review Team (MART) for a disability determination.

ACC Affordable Care Coverage -- Medicaid and Private Health Insurance with Financial Help (ACC): Medicaid is available for

parents/caretakers with income up to 136% of the Federal Poverty Level (FPL), children with income up to 261% of the FPL, pregnant women

with income up to 253% of the FPL and adults age 19 to 64 with income up to 133% of the FPL who are otherwise ineligible for Medicaid and not

eligible for or enrolled in Medicare through this eligibility pathway. Adults who are awaiting a determination of disability by a government

agency, have resources above the limits for EAD eligibility, and/or do not meet the criteria for disability determination may apply for Medicaid

affordable care coverage through this pathway. Families and individuals not eligible for Medicaid with income below 400% of the FPL may be

eligible for a tax credit from the federal government to help pay the costs of coverage through a private a health plan. You can also apply for

coverage online at

www.healthyrhode.ri.gov or over the phone by calling the HSRI Contact Center at 1-855-840-4774.

LTSS Medicaid Long Term Services and Supports (LTSS): LTSS are available for individuals who meet the necessary level of need

and financial requirements, and for individuals with disabilities. You must meet both the financial and clinical “level of care” requirements to

qualify fo

r LTSS. For people who qualify, Medicaid LTSS may be provided in a health institution like a nursing home, at home, or in certain

pre-approved community settings including some assisted living residences. The range of long-term services Medicaid covers includes, but

is not limited to, homemaker/certified nursing assistant (CNA) services, environmental modifications, case management, self-directed care,

respite, minor home modifications and shared living/RIte at Home. The range of services and the choice of service settings depends on an

individual’s care needs.

EAD Medicaid: Health Coverage for Low-Income Elders and Persons with Disabilities and Working Adults with

Disabilities/Sherlock Plan (EAD): To qualify for Medicaid for low-income elders and persons with disabilities, an individual or member of a

couple must be age 65 years or older or living with a disability. Persons who are blind also qualify for coverage in this category. Income must be

at or below 100% of the FPL, and resources cannot exceed $4,000 for a single person and $6,000 for a couple. In addition, a person under age

65 must be determined to have a disability by the Medicaid Review Team (MART) that prevents gainful activity, including work, for a minimum of

one year. Some applicants who have income and/or resources above these amounts may qualify for Medicaid through the medically needy

pathway if they have high medical expenses each month. You will be given more information about this pathway if you do not meet the EAD

income and resource standards. People who receive Supplemental Security Income (SSI) based on age or disability are automatically eligible for

Medicaid and do not need to complete this application. People who receive Social Security Disability Insurance (SSDI) must apply, but do not

have to undergo a disability review by the MART.

Medicaid for Working People with Disabilities Program/Sherlock Plan: People eligible under this category are entitled to the full

scope of Medicaid benefits, home and community-based services, and services needed to gain and/or maintain employment. To be found

eligible for this program, a person must be at least eighteen (18) years of age, meet the Medicaid requirements for eligibility based on a disability,

have proof of active, paid employment, have income at or below 250% of the FPL and meet special resource standards.

MPP Medicare Premium Payment Program (MPP): Eligibility for the MPP is based on income and helps adults over age 65 and adults

with disabilities pay all or some of the costs of Medicare Part A and Part B premiums, deductibles and co-payments. Medicare Part A is hospital

insurance coverage and Medicare Part B is for physician services, durable medical equipment and outpatient services. People with income up to

135% of the FPL are eligible to participate in MPP.

KB Katie Beckett (KB): Katie Beckett provides Medicaid/health insurance coverage to children under age 19 who are living at home but

have complex health needs that typically require the care provided in a health facility like a hospital or nursing home. To determine Katie Beckett

eligibility, only the income and resources of the child who needs coverage are considered. A child may qualify for the same services available

through this pathway if family income is within the limits for coverage for the ACC groups. Call 1-855-MYRIDHS (1-855-697-4347) if you need more

information about which pathway is best for you.

DHS-2 Rev. 09-16

Application Page

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RHODE ISLAND DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR ASSISTANCE (DHS-2)

Do you need: Help filling out this application?  Free language help?

Preferred language: _______________________________ Preferred language read:_________________________________

I want to apply for:



RIW

CASH ASSISTANCE (RHODE ISLAND WORKS- RIW)



ACC

MEDICAID/PRIVATE HEALTH INSURANCE WITH FINANCIAL

HELP (ACC)



SNAP

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM

(SNAP)



LTSS

MEDICAD: LONG-TERM SERVICES AND SUPPORTS (LTSS)



CCAP

CHILD CARE ASSISTANCE PROGRAM (CCAP)



KATIE BECKETT: HEALTH COVERAGE FOR CHILDREN WITH

SEVERE DISABILITIES (KB)



GPA

GENERAL PUBLIC ASSISTANCE (GPA)



MPP

MEDICARE PREMIUM PAYMENT PROGRAM (MPP)



SSP

RI SSI STATE SUPPLEMENTAL PAYMENT PROGRAM

(SSP)



EAD

MEDICAID HEALTH COVERAGE FOR AGE 65 AND OVER,

BLIND OR DISABLED OR

PERSONS WITH DISABILITIES

AND WORKING ADULTS WITH DISABILITIES/SHERLOCK

PLAN

(EAD)

First Name, Middle Initial, Last Name Suffix

E-Mail Address

Telephone Number

( )



Cell Home Work

Street Address

Apartment/Unit Number:

City/Town

State

Zip Code

Alternate Telephone Number:

( )

Cell



Home



Work

Are you homeless? YES NO

Best time to contact you: morning afternoon evening night weekend anytime

If your mailing address is different, please fill it in below. If not, please leave blank.

Street or PO Box Address

City

State

Zip Code

FOR SNAP APPLICANTS ONLY: Answer the questions below to see if you can get SNAP benefits faster (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, you may be eligible for expedited service.

How much money do members of your household have in cash or money in the bank? $

What is the total amount of income from any source (including unearned income such as Child Support, SSI, TDI, Unemployment, or

SSDI, RSDI, etc.) you expect your household to receive this month? $_________________

What is your current monthly rent/mortgage payment? $ Utilities? $

________________

Do you pay to heat or cool your home? Yes No

Is anyone in your household a migrant or seasonal farm worker? Yes No

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

You may tear off this sheet and submit JUST the front and backside of this page with your Name, Address and Signature to allow us to

date stamp and start this application. To determine ongoing benefit eligibility, you must sign and complete the remainder of this

application and may bring or mail or fax the application to the DHS office.

DHS-2 Rev. 09-16

Application Page

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If you would like someone to apply on your behalf, authorize someone to use your benefits, and/or receive important notices or bills for health

insurance, answer the questions below. Selecting an Authorized Representative is optional. You and your Authorized Representative will both

have access to your electronic account. If you want to name an Authorized Representative, check “Yes” below and enter his or her details. Your

authorized representative must be 18 or older and can be a friend, relative, or anyone else you choose.

Do you want this person to:



Apply for benefits on your behalf? Use your benefits? (SNAP & RIW Cash benefits only) Receive Notices?

HOUS

EHOLD COMPOSITION: Please list the members of your household below.

• SNAP Applicants: list yourself and everyone who lives in your home now, even if they do not want assistance.

• Health Coverage/ACC Applicants: include yourself, other family members, and anyone who is included on your federal tax return, if you file one.

Only include your unmarried partner (boyfriend or girlfriend) if you live together AND have a child together. Do not include your roommate. You can

complete an application for other people in your family even if you don’t need coverage or are not eligible for coverage.

Household members choosing not to seek benefits are not required to answer questions about Social Security Numbers or Citizenship information.

Name

(First, Last, Middle Initial, Suffix)

D.O.B.

(mm/dd/yyyy)

Gender

M: Male

F: Female

Social Security

Number

(

Required only if applying for

benefits)

Is this person’s name different

on his/her Social Security Card?

If yes, write the name on the card

below

U.S. Citizen?

(Required only if

applying for

benefits)

Yes No



Yes



Yes No

If there are more people in your household, please list them on page 27 marked, “for applicant/recipient use only”.

If you are applying for SNAP benefits, how would you like to be interviewed?



Telephone Interview (OR)



In-Office Interview

(Note: an in-office interview is required for RIW cash assistance. Your SNAP and RIW interview can be combined.)

Telephone#: Day__________________________________________ Evening:_________________________________________

We may need to contact you regarding the status of your application and/or to request additional

information. What is your preferred

method of contact?

Email Paper Mail

Note: If you are applying for SNAP and you select “email”, you will continue to receive notices in the mail at this time

I live in a (check one):

Elderly/Disabled Housing

Homeless: lobby, street, car

Own Home/Trailer

Shelter/Halfway House

Rent home/apt/trailer

Living in another’s home/apartment

Drug/Alcohol rehab center

No permanent address



Nursing Home/Facility:

Name of Facility:



Residential care/Assisted Living:

Name of Facility:

Other (describe):

Is anyone in the household applying for dental coverage? Yes No If yes, please write their names below:

1._______________________________________________________ 4.__________________________________________________

2._______________________________________________________ 5.__________________________________________________

3._______________________________________________________ 6.__________________________________________________

Authorized Representative’s Name

Mailing Address

Primary Phone Number ( )

Cell Work Other

Secondary Phone Number ( )

Cell Work Other

Email Address

Preferred method of contact

Email Phone Paper Mail

Preferred time of contact?

Morning Afternoon Evening Anytime

Preferred Language Spoken

English Español Português

Preferred Written Language

English Español Português

Company/Organization Name and ID (if applicable)

HS-2 Rev. 09-16

Application Page

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Please fill out some additional information below about each member of your household.

**Race/Ethnicity Information: We ask you to provide this information so we can make sure that all people are able to get the benefits

they need and we are not discriminating against anyone. You do not have to provide this information. If you choose not to provide

this information, it will not affect your eligibility for benefits. You may select more than one category under “race”.

Name

Relationship

to Primary

Applicant

Lives with Primary Applicant?

Yes or No

If no, enter address

Ethnicity

Enter a

number

(see below)

Race

Enter a

number

(see below)

Marital Status

Applying for

Benefits?

Self

Yes



No, Address:

Yes No

Yes



No, Address:

Yes No

Yes No, Address:

Yes No

Yes No, Address:

Yes No

Yes No, Address:

Yes No

Yes No, Address:

Yes No

Yes No, Address:

Yes No

Ethnicity: 1-Hispanic 2-Non-Hispanic 3-Mexican 4-Puerto Rican 5-Cuban 6-Other Hispanic

Race: 1-White 2-Black or African American 3- American Indian or Alaskan Native 4-Asian 5-Asian Indian 6-Chinese 7-Filipino 8-Japanese

9-Korean 10-Vietnamese 11-Other Asian 12-Guamanian 13-Chamorro 14-Samoan 15-Native Hawaiian 16-Other Pacific Islander

17-Other

Is any applicant getting benefits/receiving assistance in another state? YES NO

If, YES, Who?________________________________________________________ Which State?_____________________________

Before now, has any applicant ever applied for, or received any type of assistance payments, benefits or SNAP/Food Stamp benefits in

Rhode Island or in another state?

YES NO

If, YES, Who?________________________________________________________ Which State?_________________________________

Under what name?____________________________________________________ When?_______________________

What type(s) of benefits were received?______________________________________________________________________________

RIW

SNAP

CCAP

GPA

SSP

ACC

LTSS

EAD

MPP

RIW

SNAP

CCAP

GPA

SSP

ACC

LTSS

EAD

MPP

SNAP

DHS-2 Rev. 09-16

Application Page

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The Rhode Island Department of Human Services (DHS) uses an automatic phone 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, you will automatically be contacted

at the number you write on this application, unless you choose to opt out below.

Check here if you would not like to receive information about next steps in the application process from an automated telephone system: 

Is any applicant imprisoned (detained or jailed)? YES NO

If, YES, Who?_________________________________________________________ Which facility?_______________________________

Date of imprisonment:___________________________________ Date of release_________________________________

Was any applicant in the care and custody of the RI Department of Children, Youth and Families on his/her 18

birthday? YES NO

If, YES, Who?____________________________________________________________________________________________________

Is any applicant pregnant? Yes No

If Yes, please fill in the boxes below for each person who is pregnant.

Last Name First Name Middle Initial

Pregnancy Due Date

Number of Babies Expected

Is any applicant a honorably discharged veteran or active duty member of the military? Yes No

If, YES, Who?_______________________________________________________________________________________________

Is any applicant a military veteran, a dependent of a veteran, or a survivor of a veteran? Yes No

If, YES, Who?______________________________________________________ Check one: veteran child spouse

Is any applicant an American Indian or Alaskan Native? YES NO

If yes, you may be eligible for Rhode Island Medicaid protections and for special benefits. Fill in the information below.

Is any applicant a member of a Federally Recognized Tribe? Yes No If yes, who?________________________________________

Tribe Name:_________________________________________________________ Tribe State:__________________________________

Has this person ever received services from the Indian Health Service, Tribal Program or Urban Indian Health Program? Yes No

Is this person eligible to get services from the Indian Health Service, Tribal Health Program, or Urban Indian Health Programs through a

referral from one of these programs? Yes No

RIW

SNAP

RIW

SNAP

CCAP

GPA

SSP

ACC

LTSS

EAD

MPP

ACC

RIW

CCAP

GPA

SSP

ACC

LTSS

EAD

MPP

RIW

SNAP

ACC

LTSS

EAD

MPP

RIW

SNAP

ACC

LTSS

EAD

MPP

ACC

DHS-2 Rev. 09-16

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If you are applying for SNAP, you will need to select a head of household. A head of household is typically an adult parent of the

children in the home or a person who is working and providing financial support for the household. If there is no parent or working

individual, you can select any adult to be the head of household. Please select a head of household below.

Last Name First Name Middle Initial

Is there anyone who lives with you who purchases and prepares

food separately?

YES NO

If yes, list the people who purchase and prepare food separately.

Last Name First Name Middle Initial

re you or anyone in your household not a U.S. citizen? YES NO

If yes, fill in the information in the boxes below for each individual who is

requesting benefits and is not a U.S. citizen.

If you are applying for Child Care or Katie Beckett, answer this question for the child only.

**If you are a non-citizen applying for benefits, the information you provide below will be subject to verification by the United States Citizenship and

Immigration Services (USCIS- formerly known as INS) through submission of information from this application to USCIS. Submitted information

received from USCIS may affect your household’s eligibility and level of benefits. Household members choosing not to seek benefits are not

required to provide citizenship/immigration information. Household members who are seeking benefits must supply information about citizenship

or immigration status. The amount of benefits will depend on the number of people requesting benefits, but eligible household members who

apply will be able to get benefits even though some people in the household are not seeking benefits. Household members who are not seeking

benefits will be required to provide their financial information if it is needed to determine eligibility and benefit amount for persons who are

applying.

*Non-Ci

tizen Status: 1- Lawful Permanent Resident (LPR/Green Card) 2-Asylee 3-Refugee 4- Cuban/Haitian Entrant 5-Paroled into the U.S.

6-Conditional Entrant 7-Battered Spouse/Child/Parent 8-Victim of Trafficking 9-Granted Withholding of Deportation/Removal 10-Work Visa

11-Student Visa 12-Temporary Protected Status 13-Lawful Temporary Resident 14-Other (please describe)

Person 1

Last Name

First Name

Middle Initial

*Non-Citizen Status (enter a number from above):

Please provide information on your documentation below:

Alien Registration #____________________________ Naturalization Certificate #____________________________

Permanent Resident Card (Green Card, I-551): Employment Authorization Card (I-766):

Alien #________________________________ Alien #_____________________________________________

Card #________________________________ Arrival/Departure Record (I-94, I-94A) issued by USCIS:

Machine Readable Immigrant Visa (with temporary I-551 language) SEVIS ID________________________________

Visa #________________Country of Issuance_______________ Student and Exchange Visitor Information System (SEVIS) ID:

Alien #__________________________________ ________________________________________

Refugee Travel Document (I-571)#________________________ Certificate of Eligibility for Nonimmigrant (F-

1) Student Status

Foreign Passport Number______________________________ (I-20): SEVIS ID____________________________________

Reentry Permit (I-327)#:________________________________ Country of Issuance:_________________________________

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Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019) Temporary I-551 Stamp (on passport or I-94, I-94A)

SEVIS ID________________________________________________ Country of Issuance: _______________________________

Country of Issuance_______________________________________ Alien Number:________________________

Other documents or status types:

Document Description__________________________________ Alien #____________________SEVIS ID_________________________

If your name is different on your immigration document, please provide the name on the document:

Document Expiration Date:______/_____/__________ Date of Entry into U.S.: ______/_____/__________

Country of Origin:_____________________________ Lived in the U.S. before 08/22/1996?

 Yes  No

If this individual has applied for or received permanent residence status, please provide the USCIS/INS Status Date/Permanent Residence

Date:

______/_____/__________

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Does this individual have a Sponsor?



Yes



No If yes, what is the type of sponsor?



Individual



Agency/Organization

Is the sponsor a member of the household? Yes No If yes, name of household member:___________________________________

If the sponsor is a person/organization outside of the household, please provide the following information:

Organization Name:___________________________________________ Sponsor Name:_______________________________________

Address:____________________________________________________ Primary Phone Number:________________________________

Secondary Phone Number:_____________________________________ Email Address:_______________________________________

Are you or anyone in the household living with a mental, emotional or physical disability or illness, or blind? YES NO

If yes, complete the boxes below for each person.

Person 1:

Last Name First Name Middle Initial

Medical problem (describe)

Caused by an

accident?

Yes No

Has this person applied for SSI or Social Security Benefits (SSDI)?



Yes



No If yes, date applied:______/______/__________

Has the Social Security Administration made an official decision that this person is living with a disability or blind? Yes No

Is this person receiving services for with the RI Office of Rehabilitation Services or Services for

the Blind? Yes No

If this person is a parent who is not working, does this person’s disability make

him/her unable to care for the child(ren)?



Yes



Is this disability expected to last at least 12 months and will it prevent this person from working or going to school?



Yes



Does this person need help with activities of daily living such as bathing, dressing, getting into bed, daily chores, etc.?



Yes



Does this person need long-term care services at home or in a community or health facility setting like a nursing home to help with the

condition?

Yes No

Person 2:

Last Name First Name Middle Initial

Medical problem (describe)

Caused by an

accident?

Yes No

Has this person applied for SSI or Social Security Benefits (SSDI)? Yes No If yes, date applied:______/______/__________

Has the Social Security Administration made an official decision that this person is living with a disability or blind? Yes No

Is this person active with the Office of Rehabilitation Services or Services for

the Blind? Yes No

If this person is a parent who is not working, does this person’s disability make

him/her unable to care for the child(ren)?



Yes



Is this disability expected to last at least 12 months and will it prevent this person from working or going to school? Yes No

Does this person need help with activities of daily living such as bathing, dressing, getting into bed, daily chores, etc.? Yes No

Does this person need long-term care services at home or in a community or health facility setting like a nursing home to help with the

condition?

Yes No

Do you or anyone in the household expect income from a job this month? YES NO

Note: If you are self-employed, you will be asked to provide that information in the next question.

EXAMPLES: Salaries/Wages, Commissions, National Guard, Army Reserve, Work Study, Job Training, Sheltered Workshop, U.S. Military,

Jury Duty, Foreign Earned Income

If yes, complete the boxes below for each person who is employed and each job.

Person 1/Job 1:

Last Name First Name Middle Initial

Employer Name, Address and/or Employer Identification Number, if available

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Date Job Began/Will Begin

Type of Work

Day of Week Paid

How Often Paid:



Hourly



Weekly



Every two weeks



Twice a month



Monthly



Yearly



Other

Average hours worked each week____________________

List below the gross amount paid on each pay day over the last 30 days.

Pay Day

Date Paid

Pay period end date

Hours worked per pay

period

Gross wages before

taxes

Tips/Commissions

Did you receive earned income tax credit in your paycheck?



Yes



Is this job part of a work study program?



Yes



Is this an On the Job training program?



Yes



Will this income be received in the following month?



Yes



List the number of hours and amount you expect to be paid for next month:

Number of Hours: Expected Gross Earnings:$ Tips/Commissions: $

Does this person have work related expenses required

by the employer or due to being blind or disabled?



Yes



If yes, expense type:

Expense amount:

Did this person receive unemployment compensation in

the last 12 months? Yes No

If yes, dates received:

From to

Did this person refuse a job or training program

offer in the last 30 days?

Yes No

If this person’s income is not the same from month to month, how much do you think this person will make next year? $

Person 2/Job 2:

Last Name First Name Middle Initial

Employer Name, Address and/or Employer Identification Number, if available

Date Job Began/Will Begin

Type of Work

Day of Week Paid

How Often Paid:



Hourly



Weekly



Every two weeks



Twice a month



Monthly



Yearly



Other

Average hours worked each week____________________

List below the gross amount paid on each pay day over the last 30 days.

Pay Day

Date Paid

Pay period end date

Hours worked per pay

period

Gross wages before

taxes

Tips/Commissions

Did you receive earned income tax credit in your paycheck?



Yes



Is this job part of a work study program? Yes No

Is this an On the Job training program?



Yes



Will this income be received in the following month?



Yes



List the number of hours and amount you expect to be paid for next month:

Number of Hours: Expected Gross Earnings:$ Tips/Commissions: $

Does this person have work related expenses required

by the employer or due to being blind or disabled?



Yes



If yes, expense type:

Expense amount:

Did this person receive unemployment compensation in

the last 12 months? Yes No

If yes, dates received:

From to

Did this person refuse a job or training program

offer in the last 30 days?

Yes No

If this person’s income is not the same from month to month, how much do you think this person will make next year? $

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Person 3/Job 3:

Last Name First Name Middle Initial

Employer Name, Address and/or Employer Identification Number, if available

Date Job Began/Will Begin

Type of Work

Day of Week Paid

How Often Paid:



Hourly



Weekly



Every two weeks



Twice a month



Monthly



Yearly



Other

Average hours worked each week____________________

List below the gross amount paid on each pay day over the last 30 days.

Pay Day

Date Paid

Pay period end date

Hours worked per pay

period

Gross wages before

taxes

Tips/Commissions

Did you receive earned income tax credit in your paycheck?



Yes



Is this job part of a work study program? Yes No

Is this an On the Job training program?



Yes



Will this income be received in the following month?



Yes



List the number of hours and amount you expect to be paid for next month:

Number of Hours: Expected Gross Earnings:$ Tips/Commissions: $

Does this person have work related expenses required

by the employer or due to being blind or disabled?



Yes



If yes, expense type:

Expense amount:

Did this person receive unemployment compensation in

the last 12 months? Yes No

If yes, dates received:

From

Did this person refuse a job or training program

offer in the last 30 days?

Yes No

If this person’s income is not the same from month to month, how much do you think this person will make next year? $

Do you, your spouse, or anyone in the household receive income from self-employment? YES NO

EXAMPLES: Home Business, On

line Sales (ex. EBay, Craigslist), Farming, Fishing, Babysitting/Child Care, Door-to-door Sales, Home Sales,

House Cleaning

If yes, complete the boxes below about each person. Attach documentation of expenses.

Person 1/Job 1:

Last Name First Name Middle Initial

Gross Income/How Often

per

Average number of

hours worked per week

Type of Business

Name of Business

Will this income be received in

the following

months?

YES NO

Total Monthly Business Related

Expenses:

$_______________________

How much net income (income minus expenses) will you get from this

self

-employment this month?

Check one:

$_______________________________

Profit Loss

If caring for children in your home, number of children cared for:

Number of weeks worked:

Person 2/Job 2:

Last Name First Name Middle Initial

Gross Income/How Often

per

Average number of

hours worked per week

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Type of Business

Name of Business

Will this income be received in

the following

months?



YES



Total Monthly Business Related

Expenses:

$_______________________

How much net income (income minus expenses) will

you get from this self

-employment this month? Check one:

$_______________________________

Profit Loss

If caring for children in your home, number of children cared for:

Number of weeks worked:

Do you, or your spouse, or anyone in the household receive or expect to

receive, income other than from a job or self-employment, such as

the types below? (This includes money given to you by a friend or relative

.) YES NO

If yes, complete the boxes below for each person.

If you are applying for ACC only, do not report Supplemental Security Income (SSI), Veterans Disability Benefits, child support, gifts, proceeds

from loans (such as student loans, home equity loans, or bank loans) or scholarships for classes. Provide more information about your dividend

payments, interest payments, capital gains or losses, or income from partnership corporations not included in your self-employment income.

For all other programs, list the portion of student loans, scholarships, awards or fellowship grants used for living expenses.

Person 1:

Last Name First Name

Middle Initial

Amount/How Often

$___________per_____________

Date Income Received

_______/_______/__________

Claim Number (if applicable)

Type of Income

Will this income be received in the

following months?

YES



Do you have any expenses

withheld from or related to this

income? YES NO

If yes, please describe the expense(s):

Amount of expense(s):

_______________________________

Person 2:

Last Name First Name

Middle Initial

Amount/How Often

$___________per_____________

Date Income Received

_______/_______/__________

Claim Number (if applicable)

Type of Income

Will this income be received in the

following months?

YES NO

Do you have any expenses

withheld from or related to this

income? YES NO

If yes, please describe the expense(s):

Amount of expense(s):

_______________________________

Person 3:

Last Name First Name

Middle Initial

Amount/How Often

$___________per_____________

Date Income Received

_______/_______/__________

Claim Number (if applicable)

Type of Income

Will this income be received in the

following months?

YES



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EXAMPLES:

Adoption Subsidy

Court Award

401(k)

Gifts, Prizes, Inheritance, Lottery

Railroad Retirement

Royalties

Unemployment Compensation

Cash Support

Alien Sponsorship

In-kind Shelter

Retirement Pensions

VA Aid and Attendance

Alimony

Income Tax Refund

Social Security (RSDI)

VA Compensation

Annuities

Other in-kind

Section 8 Utility Payment

VA Basic Benefits

Net Capital Gains/Investment

Income

Gambling winnings

Royalty Income

Interest Income

Income from Partnership Corporations

Child Support

Insurance and Lawsuit Claim

SSI, SSDI

VA Improved Pension

Dividends, Interest

Strike Benefits

Workers’ Compensation

IRA Distributions

Earned Income Tax Credit Refund

Military Allotment

TDI

Promissory Note

Foster Care

Out of State Assistance

Trust Funds

Student Income (Loans, Grants, Scholarships)

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Do you have any expenses

withheld from or related to this

income? YES NO

If yes, please describe the expense(s):

Amount of expense(s):

_______________________________

rson 4:

Last Name First Name

Middle Initial

Amount/How Often

$___________per_____________

Date Income Received

_______/_______/__________

Claim Number (if applicable)

Type of Income

Will this income be received in the

following months?

YES



Do you have any expenses

withheld from or related to this

income? YES NO

If yes, please describe the expense(s):

Amount of expense(s):

_______________________________

If anyone in the household expects income within the next 12 months, fill in the box below for that person.

Last Name

First Name

Middle Initial

Type of income Expected

Expected Date income will be

received

Please report any additional allowable tax deductions not previously reported on this application.

The purpose of a tax reduction is to reduce your taxable income. If you pay any of the expenses listed below, that means your income is lower and

it may lower the cost of your health insurance. If you have previously reported expenses in questions 15 - 17, you do not have to report them

again here.

Examples of allowable deductions:

Health Savings Account (HSA) Contributions Interest Paid on Student Loans IRA/401K Deductions

Self-Employment Retirement Plans and Self-Employment Health Insurance Educator Expenses Domestic Product Activities

Penalties Paid for Early Withdrawal from Savings Tuition and School Fees Business expenses of

Moving Costs Related to a job change performing artists, reservists, and fee-basis

government officials

Alimony Paid

Who?_______________________________

How much?__________________________

How Often?__________________________

Student Loan Interest

Who?_______________________________

How much?__________________________

How Often?__________________________

Tuition and School Fees

Who?_______________________________

How much?__________________________

How Often?__________________________

Other_____________________________

Who?_______________________________

How much?__________________________

How Often?__________________________

 Other____________________________

Who?_______________________________

How much?__________________________

How Often?__________________________

 Other_____________________________

Who?_______________________________

How much?__________________________

How Often?__________________________

Please complete the boxes below for every household member even if the tax payer or tax dependent is not in your home.

Name

Does this person

plan to file a federal

income tax return

next year?

Will this person file

jointly with a

spouse/partner?

(If married, you have to file

jointly to qualify for a tax

credit)

Does this person

have any tax

dependents?

(A dependent can be

claimed by only one tax

ﬁler. For joint ﬁlers, you

need to list dependents for

the tax ﬁler who will

sign the tax form.)

Is this person

claimed as a tax

dependent on

someone else’s tax

return?

How is this

person related to

the tax filer?

YES NO

If yes, name of spouse

or partner:

YES NO

If yes, name of tax

dependents:

YES NO

If yes, name of the tax

filer:

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YES NO

If yes, name of spouse

or partner:

YES NO

If yes, name of tax

dependents:

YES NO

If yes, name of the tax

filer:

YES NO

If yes, name of spouse

or partner:

YES NO

If yes, name of tax

dependents:

YES NO

If yes, name of the tax

filer:

YES NO

If yes, name of spouse

or partner:

YES NO

If yes, name of tax

dependents:

YES NO

If yes, name of the tax

filer:

Is anyone in the household enrolled in or does anyone in the household have access to health coverage now? YES NO

If yes, complete the boxes below for each person/type of insurance.

*Examples of Insurance Types: Tricare, Veteran’s Health Insurance, Peace Corps, Medicare, Employer Insurance, Private Insurance, Cobra,

Dental Insurance, Retiree Plan, Other

Name

Insurance Company

Name

Insurance Policy # or

Medicare Claim #

*Insurance Type

(see examples above)

Currently

Enrolled?

____________________

Monthly

Premium:____________

_________________________

Check one: Individual

Family

YES NO

If no, plans to enroll?

YES NO

Start Date:

____________________

Monthly

Premium:____________

_________________________

Check one: Individual

Family

YES NO

If no, plans to enroll?

YES NO

Start Date:

____________________

Monthly

Premium:____________

_________________________

Check one: Individual

Family

YES NO

If no, plans to enroll?

YES NO

Start Date:

____________________

Monthly

Premium:____________

_________________________

Check one: Individual Family

YES NO If no,

plans to enroll?

YES NO

Start Date:

____________________

Monthly

Premium:____________

_________________________

Check one: Individual

Family

YES NO

If no, plans to enroll?

YES NO

Start Date:

____________________

Monthly

Premium:____________

_________________________

Check one: Individual

Family

YES NO

If no, plans to enroll?

YES NO

Start Date:

Please fill in the information below if there are any upcoming changes to any of the employer insurance listed above.

Name of person with employer coverage:______________________________________________

Employer plans to drop plan on (MM/DD/YYYY):____________________ Will become eligible on (MM/DD/YYYY):___________________

Name of person with employer coverage:______________________________________________

Employer plans to drop plan on (MM/DD/YYYY):_____________________Will become eligible on (MM/DD/YYYY):___________________

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Fill in the information below for all family members applying for health coverage.

Name: Last covered by health insurance:



Within the last year:______/_____/______



1-3 years ago

More than 3 years ago Never Other/Uninsured

Name: Last covered by health insurance: Within the last year:______/_____/______ 1-3 years ago

More than 3 years ago Never Other/Uninsured

Please fill in the boxes below about the educational background of each member of your household.

Person 1:

Name

Highest Grade Completed

High School Graduation Date

(if graduated):_____/_____/______

Received GED?

Yes 

In School Now?

Yes No

If in school, name of school:

Attending:



Full Time



Half Time



Less than Half Time

Type: K-12 GED Vocational College/University Trade School Other Expected Graduation Date: ______/______/________

Participating in a work study program?



Yes



Participating in a training program?



Yes



If yes, name of training program:

Person 2:

Name

Highest Grade Completed

High School Graduation Date

(if graduated):_____/_____/______

Received GED?

Yes 

In School Now?

Yes No

If in school, name of school:

Attending:



Full Time



Half Time



Less than Half Time

Type: K-12 GED Vocational College/University Trade School Other Expected Graduation Date: ______/______/________

Participating in a work study program?



Yes



Participating in a training program?



Yes



If yes, name of training program:

Person 3:

Name

Highest Grade Completed

High School Graduation Date

(if graduated):_____/_____/______

Received GED?

Yes 

In School Now?

Yes No

If in school, name of school:

Attending:



Full Time



Half Time



Less than Half Time

Type: K-12 GED Vocational College/University Trade School Other Expected Graduation Date: ______/______/________

Participating in a work study program?



Yes



Participating in a training program?



Yes



If yes, name of training program:

Person 4:

Name

Highest Grade Completed

High School Graduation Date

(if graduated):_____/_____/______

Received GED?

Yes 

In School Now?

Yes No

If in school, name of school:

Attending:



Full Time



Half Time



Less than Half Time

Type: K-12 GED Vocational College/University Trade School Other Expected Graduation Date: ______/______/________

Participating in a work study program?



Yes



Participating in a training program?



Yes



If yes, name of training program:

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e you, your spouse, or anyone in the household in a group living arrangement such as the types listed below? YES NO

Shelter for Homeless Drug Treatment Center Hospital Group Home

Alcohol Treatment Center Domestic Violence Shelter Assisted Living Facility

Dormitory

If yes, complete the boxes below.

Last Name First Name Middle Initial

Name of Facility

Type of Facility

Number of meals

provided per day?

Are you or any member of your household hiding or running from the law to avoid prosecution, being taken into custody, or

going to jail, for a felony crime or attempted felony crime, or violating a condition or parole or probation? YES NO

If yes, complete the boxes below for each household member.

Last Name First Name Middle Initial

Date of Finding

State

If you are applying for child care assistance, please tell us about your schedule regarding your need for child care. Fill in the table

below with the reason you need child care and enter the time for child care on each day.

Person 1:

Parent’s Name:

Child’s Name:

Day

Need Reason (check the appropriate boxes)

Start Time

End Time

Monday

Work High School/GED Completion

Special Needs due to Health Condition

Tuesday

Work High School/GED Completion

Special Needs due to Health Condition

Wednesday

Work High School/GED Completion

Special Needs due to Health Condition

Thursday

Work High School/GED Completion

Special Needs due to Health Condition

Friday

Work High School/GED Completion

Special Needs due to Health Condition

Saturday

Work High School/GED Completion

Special Needs due to Health Condition

Sunday

Work High School/GED Completion

Special Needs due to Health Condition

If your schedule varies, please explain how (you may send additional documentation to verify).

Person 2:

Parent’s Name:

Child’s Name:

Day

Need Reason (check the appropriate boxes)

Start Time

End Time

Monday

Work High School/GED Completion

Special Needs due to Health Condition

Tuesday

Work



High School/GED Completion

Special Needs due to Health Condition

Wednesday

Work



High School/GED Completion

Special Needs due to Health Condition

RIW

SNAP

LTSS

SNAP

CCAP

HS-2 Rev. 09-16

Application Page

5 of 32

Thursday

Work High School/GED Completion

Special Needs due to Health Condition

Friday

Work High School/GED Completion

Special Needs due to Health Condition

Saturday

Work High School/GED Completion

Special Needs due to Health Condition

Sunday

Work High School/GED Completion

Special Needs due to Health Condition

If your schedule varies, please explain how (you may send additional documentation to verify).

Do you, your spouse or anyone in the household pay for room and/or board? YES NO

If yes, complete the box below for the household member who pays for room and/or board.

Last Name

First Name

Middle Initial

Amount Paid/How Often

What does the room/board cover?

per

Room only Board (1-2 meals) Board (3 meals)

Who is the room/board payment paid to?

Does anyone in your household, including you, have a legal claim or lawsuit for illnesses or injuries resulting from a car or workplace

accident or other matter in which you may receive money? YES NO

If yes, complete the boxes below for each person.

Last Name First Name Middle Initial

Type of Claim (describe)

Date of Incident

Workers’

Compensation

Yes No

Person (or company)

responsible/Address

Insurance Company Name/ Address

Attorney Name

Attorney Address

Claim Number

27a

Are there children in the household who have a parent (natural or adoptive) living outside the home or deceased? YES NO

If applying for ACC, answering this question is optional. If YES, I know I’ll be asked to cooperate with the Ofﬁce of Child Support Services that

collects medical support from a non-custodial parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the

agency and I may not have to cooperate.

27b

If you answered yes to question #27a and are applying for RIW and/or CCAP, please fill in the boxes below for each parent living

outside the home (non-cus

todial parent) or deceased.

State law assumes a child born during the time a couple is married or within 10 months of a final decree of divorce to be their child. List the present or former

spouse as the non-custodial parent of the child(ren) born during that time. If divorce decree or court order excludes your spouse or former spouse as

father of any of the child(ren) listed in the application, you need to list the biological parent of the child(ren) and provide copies of the decree or order with this

application.

rent 1:

Non-custodial/Deceased Parent’s Last Name First Name MI

Gender



M F

Non-custodial/Deceased Parent’s SSN

Birth Date

/ /

RIW

SNAP

RIW

CCAP

GPA

SSP

LTSS

EAD

MPP

RIW

CCAP

ACC

RIW

CCAP

DHS-2 Rev. 09-16

Application Page

of 32

Non-custodial Parent’s Address

Non-custodial Parent’s Telephone Number

Employer Name

Employer Address

Is this parent disabled and/or

a veteran? Yes No

Was the child born during the marriage or within

300 days after the marriage ended due to death

or divorce? Yes No

If yes, date married

Are the parents of the child(ren)

currently married to each other?

Yes No

If no, date divorced / /

Non-custodial Parent’s Marital Status

Never Married Divorced Widowed

Married Separated Unknown

Non-custodial Parent’s

Race: Ethnicity: Hair Color: Height: Weight: Birth City: Birth State:

Has the non-custodial parent ever been in jail?

Yes No

If yes, incarceration begin date:

________/_________/_________

Incarceration end date:

________/_________/_________

Is a parent of the child(ren) deceased?

Yes No

If yes, deceased parent’s date of death:

________/_________/_________

Child(ren) of this non-custodial parent living in the applicant’s

household.

Child’s Last Name First Middle Initial

State of Birth

Is child support, health coverage or paternity court ordered?

(If yes, check off type of coverage and list date.)

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be

harmed

by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic

Violence

Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child

you

help us collect child support: 

Parent 2:

Non-custodial/Deceased Parent’s Last Name First Name MI

Gender

M



Non-custodial/Deceased Parent’s SSN

Birth Date

/ /

Non-custodial Parent’s Address

Non-custodial Parent’s Telephone Number

Employer Name

Employer Address

Is this parent disabled and/or

a veteran? Yes No

Was the child born during the marriage or within

300 days after the marriage ended due to death

or divorce? Yes No

If yes, date married

Are the parents of the child(ren)

currently married to each other?

Yes No

If no, date divorced / /

Non-custodial Parent’s Marital Status

Never Married Divorced Widowed

Married Separated Unknown

Non-custodial Parent’s

Race: Ethnicity: Hair Color: Height: Weight: Birth City: Birth State:

Has the non-custodial parent ever been in jail?

Yes No

If yes, incarceration begin date:

________/_________/_________

Incarceration end date:

________/_________/_________

DHS-2 Rev. 09-16

Application Page

of 32

Is a parent of the child(ren) deceased?

Yes No

If yes, deceased parent’s date of death:

________/_________/_________

Child(ren) of this non-custodial parent living in the applicant’s

household.

Child’s Last Name First Middle Initial

State of Birth

Is child support, health coverage or paternity court ordered?

(If yes, check off type of coverage and list date.)

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date / /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be

harmed

by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic

Violence

Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child

you

help us collect child support: 

rent 3:

Non-custodial/Deceased Parent’s Last Name First Name MI

Gender



M F

Non-custodial/Deceased Parent’s SSN

Birth Date

/ /

Non-custodial Parent’s Address

Non-custodial Parent’s Telephone Number

Employer Name

Employer Address

Is this parent disabled and/or

a veteran? Yes No

Was the child born during the marriage or within

300 days after the marriage ended due to death

or divorce? Yes No

If yes, date married

Are the parents of the child(ren)

currently married to each other?

Yes No

If no, date divorced / /

Non-custodial Parent’s Marital Status

Never Married Divorced Widowed

Married Separated Unknown

Non-custodial Parent’s

Race: Ethnicity: Hair Color: Height: Weight: Birth City: Birth State:

Has the non-custodial parent ever been in jail?

Yes No

If yes, incarceration begin date:

________/_________/_________

Incarceration end date:

________/_________/_________

Is a parent of the child(ren) deceased?

Yes No

If yes, deceased parent’s date of death:

________/_________/_________

Child(ren) of this non-custodial parent living in the applicant’s

household.

Child’s Last Name First Middle Initial

State of Birth

Is child support, health coverage or paternity court ordered?

(If yes, check off type of coverage and list date.)

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date / /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

DHS-2 Rev. 07-16 Application Page

of 30

DHS-2 Rev. 09-16

Application Page

of 32

We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be

harmed

by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic

Violence

Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child

you

help us collect child support: 

Person 4:

Non-custodial/Deceased Parent’s Last Name First Name MI

Gender



M F

Non-custodial/Deceased Parent’s SSN

Birth Date

/ /

Non-custodial Parent’s Address

Non-custodial Parent’s Telephone Number

Employer Name

Employer Address

Is this parent disabled and/or

a veteran?



Yes



Was the child born during the marriage or within

300 days after the marriage ended due to death

or divorce? Yes No

If yes, date married

Are the parents of the child(ren)

currently married to each other?

Yes No

If no, date divorced / /

Non-custodial Parent’s Marital Status

Never Married Divorced Widowed

Married Separated Unknown

Non-custodial Parent’s

Race: Ethnicity: Hair Color: Height: Weight: Birth City: Birth State:

Has the non-custodial parent ever been in jail?

Yes No

If yes, incarceration begin date:

________/_________/_________

Incarceration end date:

________/_________/_________

Is a parent of the child(ren) deceased?

Yes No

If yes, deceased parent’s date of death:

________/_________/_________

Child(ren) of this non-custodial parent living in the applicant’s

household.

Child’s Last Name First Middle Initial

State of Birth

Is child support, health coverage or paternity court ordered?

(If yes, check off type of coverage and list date.)

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date / /

Yes

No

Support

Health

Cov

Paternity



Date / /

Date

/ /

Date

/ /

We ask information about the non-custodial parent so that we can seek child support from him/her. If you fear that you or your child will be

harmed

by the non-custodial parent if you help us in this process, you may be excused from cooperating. We will refer you to a Domestic

Violence

Advocate who can discuss this with you and help with safety planning. Check this box if you fear harm to either you or your child

you

help us collect child support: 

Have you or has any member of your household been convicted of any of the offenses listed below? YES NO

If yes, please fill in the boxes below for each household member who has been convicted of an offense and check the box for

the

applicable offense on the right.

Last Name First Name Middle Initial

Check the box(es) below that apply.



Trading SNAP benefits for drugs after September 22, 1996?

Buying or selling SNAP benefits over $500 after September 22, 1996?

Fraudulently receiving duplicate SNAP benefits in any state after September 22, 1996?

Trading SNAP benefits for guns, ammunitions or explosives after September 22, 1996?

SNAP

DHS-2 Rev. 09-16

Application Page

of 32

Have

you or any member of your household been barred from participating in the SNAP/Food Stamp Program in

another state?



YES NO

If yes, complete the boxes below for each household member.

Last Name First Name Middle Initial

Date

State

Do you, your spouse, or anyone in the household own, and/or

have registered in his/her name any vehicle? YES NO

If yes, complete the boxes below for each vehicle. Examples: car, boat, camper, snowmobile, truck, motorcycle

Vehicle 1:

Owner’s Last Name First Name

Middle Initial

Vehicle Type

Make

Model Year

What is the vehicle used for? (ex: work, everyday use, transportation

for disabled household member)

Amount owed

License Plate Number

Vehicle ID Number (VIN)

Insurance Company Name:

Is vehicle registered?

Yes No

Is vehicle income producing?

Yes No

Do you currently have possession of the vehicle?

Yes No

Do you own the vehicle with someone else?

Yes No

If yes, name of person who co-owns the vehicle:

Vehicle 2

Owner’s Last Name First Name

Middle Initial

Vehicle Type

Make

Model Year

What is the vehicle used for? (ex: work, everyday use, transportation

for disabled household member)

Amount owed

License Plate Number

Vehicle ID Number (VIN)

Insurance Company Name:

Is vehicle registered?

Yes No

Is vehicle income producing?

Yes No

Do you currently have possession of the vehicle?

Yes No

Do you own the vehicle with someone else?

Yes No

If yes, name of person who co-owns the vehicle:

Certain resources/assets such as bank accounts may count toward your eligibility depending on which program you are applying for. Certain

resources/assets may not count, such as a home and lot where you live and the resources of people who receive Supplemental Security Income.

Examples of things you own include, but are not limited to: Cash on hand, checking account, savings account, trust(s), CD –Certificate of Deposit,

royalties, life or burial insurance, stocks or bonds, retirement account, livestock, house/land - not occupying, life estate, mutual funds

Do you, your spouse, or anyone in the household have any resources/assets? YES NO

SNAP

RIW

CCAP

GPA

SSP

LTSS

EAD

MPP

RIW

CCAP

GPA

SSP

LTSS

EAD

MPP

DHS-2 Rev. 09-16

Application Page

of 32

If yes, complete the boxes below for each resource/asset owned by your and anyone in your household.

Resource or Asset

Who owns it?

Value

Bank or Company Name, if Applicable

$_______________

Income producing?



Yes



$_______________

Income producing?



Yes



$_______________

Income producing?

Yes No

$_______________

Income producing?

Yes No

Did you, your spouse, or anyone in the household receive a lump sum payment such as Social Security, Retirement, Survivors and

Disability (RSDI) in the past 6 months? YES NO

If yes, complete the boxes below for each lump sum payment.

Person 1

Last Name

First Name

Middle Initial

Type of payment

Date received

Lump sum amount:

Is lump sum jointly owned?



Yes No

If yes, who is the co-owner?

Person 2

Last Name

First Name

Middle Initial

Type of payment

Date received

Lump sum amount:

Is lump sum jointly owned?



Yes No

If yes, who is the co-owner?

Have you, your spouse or anyone acting on your behalf (including a court) established a trust or put any money or other resource

into a trust within the last sixty (60) months? YES NO

s any property come out of a trust within the last sixty (60) months? YES NO

If y

es, you must provide copies of the trust and describe all such transactions into or out of the trust. Please complete the boxes

below.

Established by

Date established

Amount

_______/_______/________ $____________

Have you, your spouse, or anyone in the household given away, sold, deeded, or transferred to anyone or any entity, any items of value

in the past sixty (60) months? YES NO

If you are applying for RIW only, answer “yes” to the question only if items of value were transferred within the month you are applying for

benefits. If you are applying for SNAP benefits only and are asked to answer this question, report the items of value that were transferred

within the last three (3) months.

RIW

CCAP

GPA

SSP

LTSS

EAD

MPP

RIW CCAP GPA SSP LTSS MPP KB

RIW

EAD

LTSS

MPP

HS-2 Rev. 09-16

Application Page

of 32

If yes, complete the boxes below.

Item Transferred

Transferred to Whom?

$ Value

Date of Transfer

Did you or anyone in the household leave a job in the last sixty (60) days or is anyone on strike? YES NO

If yes, fill in the boxes below.

Last Name First Name Middle Initial

Reason for leaving job

Date left job/Date Strike Began

Employer’s Name

Employer’s Address

Do you, your spouse or anyone in your household receive income from rent? YES NO

f yes, complete the boxes below about the person who receives rent.

Last Name First Name Middle Initial

Number of Units

Does the person live here?

YES NO

Hours per week maintain

ing property:_____________

Total rent received $_________ per_________

Will this income continue in the

next months?

YES NO

Rental Expense

How Often?

Rental Expense

How Often?

Rental Expense

How Often?

Mortgage $

Taxes $

Water

Sewage

Garbage

Gas

_____________

Electric

Oil

Repairs

Other

Do you, your spouse or anyone in your household receive payment from roomers and/or boarders? YES NO

If y

es, complete the boxes below. Attach documentation if you wish to claim actual expenses.

Name of person receiving payment:

Last Name First Name Middle Initial

Number of hours worked per week:

Will this income be received in the following months?

YES NO

Names of Roomer/Boarders

Amount

Received/How Often

Includes

(check boxes)

Date

Received

$___________

per_________

Room only

Board (1-2 meals)

Board (3 meals)



______/_____/______

$___________

per_________

Room only

Board (1-2 meals)

Board (3 meals)



______/_____/______

$___________

per_________

Room only

Board (1-2 meals)

Board (3 meals)



______/_____/______

Expenses: $________________ per _______________

Type(s) of expenses:

SNAP

RIW

SNAP

CCAP

GPA

SSP

ACC

LTSS

EAD

MPP

RIW SNAP CCAP GPA SSP ACC LTSS EAD MPP KB

DHS-2 Rev. 09-16

Application Page 2

of 32

*(If you report and provide proof of your expenses you list for questions 38-42, it can help you get more benefits from SNAP and may

affect your eligibility. If you do not report an expense or provide proof, then we will assume that you do not want this expense to be

counted.)

Do you, your spouse, or anyone in the household pay for someone to care for children, elderly, or disabled adults due

to work, training,

looking for work or schooling? YES NO

EXAMPLES: Payments made to child or adult care providers for day care; Payments made for before and after school programs;

Summer camp fees; Cost of transportation to and from child/adult care providers

If yes, complete the boxes below for each person who paid for care.

Person 1:

Name of person paying for care

Day Care is needed because s/he is:

Working In school/ training

Looking for work

Is this cost

subsidized

Yes No

If yes, amount

subsidy?

per______

Name of person in care

Adult/Child

Adult

Child

Amount of out-of-pocket

Payment or co-payment

per

Will this cost continue?

Yes No

Name of Care Provider

Address of Provider

Person 2:

Name of person paying for care

Day Care is needed because s/he is:

Working In school/ training

Looking for work

Is this cost

subsidized



Yes



If yes, amount

subsidy?

per_______

Name of person in care

Adult/Child

Adult

Child

Amount of out-of-pocket

Payment or co-payment

per

Will this cost continue?

Yes No

Name of Care Provider

Address of Provider

Is there anyone in the household who is age sixty (60) or older (age 65 or older if applying for EAD/LTSS) or disabled, who incurs or has any

unpaid medical expenses not covered by health insurance?



YES



EXAMPLES: He

alth Insurance Premiums Hearing Aids Dental Care Prescription Drugs Medicare Premiums

Eyeglasses Hospital Bills Medical Equipment/Supplies

Transportation to and from Medical Treatment or Services

If yes, complete the boxes below for each person who has medical expenses or each medical expense.

rson 1/Expense 1:

Last Name First Name Middle Initial

Type of Medical Expense

Amount Incurred $

How often?

Is the medical expense

overdue? YES NO

Expense is paid to:

Date of Service

/ /

When do you expect this to end?

/ /

RIW SNAP

SNAP

LTSS

EAD

DHS-2 Rev. 09-16

Application Page 2

of 32

Person 2/Expense 2:

Last Name First Name Middle Initial

Type of Medical Expense

Amount Incurred $

How often?

Is the medical expense

overdue? YES NO

Expense is paid to:

Date of Service

/ /

When do you expect this to end?

/ /

Person 3/Expense 3:

Last Name First Name Middle Initial

Type of Medical Expense

Amount Incurred $

How often?

Is the medical expense overdue?

YES NO

Expense is paid to:

Date of Service

/ /

When do you expect this to end?

/ /

Do you, your spouse, or anyone in the household pay child support or alimony/spousal support for any person not living in this

household?



YES



If you are applying for ACC only, you need to answer this question only if you pay alimony/spousal support.

If ye

s, complete the boxes below about each person who pays child support or alimony/spousal support.

Person 1:

Person 2:

Do you, your spouse, or anyone in the household have housing bills?



YES



EXAMPLES: Rent or a share of the rent for the apartment, house, mobile home or shelter where you live homeowner’s insurance

rtgage land contract property taxes assessment fees mobile home payments condo/association fees

If ye

s, complete the boxes below for each person who pays housing bills.

SNAP

ACC

Last Name First Name Middle Initial

Who is the person claiming/Who is the support paid for?

Amount Paid

$_____________per____________

Type of claim/support:

Child Support  Medical Support Alimony/Spousal Support

Is this expense court

ordered?

YES NO

Last Name First Name Middle Initial

Who is the person claiming/Who is the support paid for?

Amount Paid

$_____________per____________

Type of claim/support:

Child Support  Medical Support Alimony/Spousal Support

Is this expense court

ordered?

YES NO

RIW

SNAP

LTSS

Last Name First Name Middle Initial

Total Rent or Mortgage

Amount/How Often

Amount Paid by you

$_________________

Shelter Type

$__________/____________

Does anyone share a cost of the housing

expense?



YES



If yes,

Name:________________________________________________________________________

Amount $___________________________

DHS-2 Rev. 09-16

Application Page

of 32

Have you or anyone in the household received low-income heating assistance within the last 12 months?



YES



Do you, or anyone in the household pay all or a share of the fuel or utilities listed below?



YES



If yes, complete the boxes below indicating which fuel/utilities are paid for and how much.

Heating or Cooling?



YES



Included in Rent?



YES



Telephone?



YES



If Yes, amount: $_________per________

Electric?



YES



If Yes, amount: $_________per________

Water?



YES



If Yes, amount: $________per_______

Sewer?



YES



If Yes, amount: $_________per________

Trash?



YES



If Yes, amount: $_________per________

After April 1977, did you ever get an SSI check at the same time that you got social security, or did you get SSI in the month just before

social security started? YES NO

If yes, fill in the boxes below.

Last Name First Name Middle Initial

Year Received

44 ACC

CONSENT FOR USE OF INCOME DATA

N ORDER TO DETERMINE YOUR ELIGIBILITY FOR HELP PAYING FOR YOUR HEALTH COVERAGE

WE WILL USE INCOME DATA

INCLUDING

INFORMATION FROM TAX RETURNS. YOU WILL RECEIVE A NOTICE WITH YOUR ELIGIBILITY DETERMINATION AND MAY MAKE CHANGES TO

UPDATE THE INCOME INFORMATION USED AT ANY TIME BY CONTACTING HEALTHSOURCE RI. CHECK ONE OF THE BOXES BELOW:

I AGREE TO GIVE MY CONSENT FOR USE OF INCOME DATA

I DO NOT GIVE MY CONSENT AND I UNDERSTAND THAT THIS WILL IMPACT MY ELIGIBILITY FOR HELPING TO PAY

FOR HEALTH COVERAGE.

YOU CAN CHOOSE TO HAVE THIS CONSENT RENEWED AUTOMATICALLY FOR ONE, TWO, THREE, FOUR OR FIVE YEARS. SELECTING A LONGER

PERIOD OF TIME MAY MAKE IT EASIER FOR US TO DETERMINE YOUR ELIGIBILITY IN FUTURE YEARS. PLEASE RENEW MY ELIGIBILITY

AUTOMATICALLY FOR THE NEXT (CHECK ONE):

5 YEARS (THIS IS THE MAXIMUM AUTOMATIC RENEWAL PERIOD) 4 YEARS 3 YEARS 2 YEARS 1 YEAR

I UNDERSTAND THAT IF RECEIVE FINANCIAL HELP TO REDUCE THE COST OF HEALTH COVERAGE FOR MYSELF AND/OR MY DEPENDENTS:

 I MUST FILE A FEDERAL INCOME TAX RETURN THE YEAR AFTER MY COVERAGE YEAR FOR THE TAX YEAR IN WHICH I RECEIVED

COVERAGE.

 IF I’M MARRIED AT THE END OF THE COVERAGE YEAR, I MUST FILE A JOINT INCOME TAX RETURN WITH MY SPOUSE.

I ALSO EXPECT THAT:

 NO ONE ELSE WILL BE ABLE TO CLAIM ME AS A DEPENDENT ON THEIR COVERAGE YEAR FEDERAL INCOME TAX RETURN.

If renting, included in rent:

Heat Utilities

If renting, is the rent subsidized?

YES NO

If yes, the amount of subsidy is

$______________

Subsidy Type

If renting, Landlord’s Name:

Landlord’s Telephone Number

Landlord’s Address:

Monthly Homeowner’s Expenses:

First Mortgage

Principal $

Interest $

Includes:

Taxes Insurance

Taxes $______________ Insurance $______________

Lot Rental $______________ Other $______________

Monthly Homeowner’s Expenses:

Second Mortgage

Principal $

Interest $

Includes:

Taxes Insurance

Taxes $______________ Insurance $______________

Lot Rental $______________ Other $______________

SNAP LTSS

EAD

DHS-2 Rev. 09-16

Application Page

of 32

 I’

LL CLAIM A PERSONAL EXEMPTION DEDUCTION ON MY COVERAGE YEAR FEDERAL INCOME TAX RETURN FOR ANY INDIVIDUAL LISTED

ON THIS APPLICATION AS A DEPENDENT WHO IS ENROLLED IN COVERAGE AND WHO RECEIVES FINANCIAL HELP FOR THIS COVERAGE.

IF ANY OF THE ABOVE CHANGES, I UNDERSTAND THAT IT MAY IMPACT MY ABILITY TO GET AN ADVANCE PREMIUM TAX CREDIT.

I ALSO UNDERSTAND THAT WHEN I FILE MY COVERAGE YEAR FEDERAL INCOME TAX RETURN, THE INTERNAL REVENUE SERVICE (IRS) WILL

COMPARE THE INCOME ON MY TAX RETURN WITH THE INCOME ON MY APPLICATION. I UNDERSTAND THAT IF THE INCOME ON MY TAX

RETURN IS LOWER THAN THE AMOUNT OF INCOME ON MY APPLICATION, I MAY BE ELIGIBLE TO GET AN ADDITIONAL TAX CREDIT AMOUNT.

ON THE OTHER HAND, IF THE INCOME ON MY TAX RETURN IS HIGHER THAN THE AMOUNT OF INCOME ON MY APPLICATION, I MAY OWE

ADDITIONAL FEDERAL INCOME TAX.

CONSENT TO IDENTITY VERIFICATION

O PROTECT YOUR PRIVACY

YOU WILL NEED TO SUCCESSFULLY COMPLETE

DENTITY

ERIFICATION BEFORE ESTABLISHING AN ONLINE

ACCOUNT WITH US AND OBTAINING ACCESS TO CERTAIN INFORMATION THAT WILL BE CONTAINED WITHIN YOUR ACCOUNT. BY CLICKING ON

THE "I AGREE" BOX YOU ARE PROVIDING YOUR CONSENT TO EXPERIAN TO ACCESS YOUR PERSONAL INFORMATION TO CONDUCT ID

VERIFICATION ON BEHALF OF CMS AND THE STATE OF RHODE ISLAND.

I AGREE TO GIVE MY CONSENT TO EXPERIAN TO CONDUCT ID VERIFICATION

I DO NOT GIVE MY CONSENT AND I UNDERSTAND THAT THIS WILL IMPACT MY ELIGIBILITY FOR HELPING TO PAY FOR

HEALTH COVERAGE.

ENSURE THAT YOU HAVE WRITTEN YOUR LEGAL NAME, CURRENT HOME ADDRESS, PRIMARY PHONE NUMBER, DATE OF BIRTH, AND EMAIL

ADDRESS CORRECTLY. FOR ONLINE ACCOUNT ACCESS, WE WILL ONLY COLLECT PERSONAL INFORMATION TO VERIFY YOUR IDENTITY WITH

EXPERIAN, AN EXTERNAL IDENTITY VERIFICATION PROVIDER. IDENTITY VERIFICATION INVOLVES EXPERIAN USING INFORMATION FROM YOUR

CONSUMER REPORT PROFILE TO HELP CONFIRM YOUR IDENTITY. AS A RESULT, YOU MAY SEE AN ENTRY CALLED A "SOFT INQUIRY" ON YOUR

EXPERIAN CONSUMER REPORT. SOFT INQUIRIES ARE ONLY VISIBLE TO YOU, WILL NEVER BE PRESENTED TO THIRD PARTIES, AND DO NOT

AFFECT YOUR CREDIT SCORE. THE SOFT INQUIRY WILL BE TITLED "CMS PROOFING SERVICES" AND WILL BE REMOVED FROM YOUR EXPERIAN

CONSUMER REPORT AFTER 25 MONTHS. YOU MAY NEED TO HAVE ACCESS TO YOUR PERSONAL AND CONSUMER REPORT INFORMATION, AS

THE EXPERIAN APPLICATION WILL POSE QUESTIONS TO YOU, BASED ON DATA IN THEIR FILES.

YOUR CONSENT TO SHARE DATA FOR ELIGIBILITY DECISIONS

E CAN HELP YOU BETTER IF WE ARE ABLE TO WORK WITH OTHER AGENCIES AND PROFESSIONALS THAT KNOW YOU AND YOUR FAMILY

CHECKING THE I AGREE BOX YOU ARE GIVING PERMISSION FOR US TO OBTAIN, USE AND SHARE CONFIDENTIAL INFORMATION ABOUT YOU

FROM A VARIETY OF SOURCES INCLUDING THE R.I. DEPARTMENT OF LABOR AND TRAINING, THE R.I. DEPARTMENT OF HUMAN SERVICES,

THE R.I. EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES, THE R.I. DEPARTMENT OF HEALTH, THE R.I. DEPARTMENT OF

CORRECTIONS, AND EXPERIAN ON BEHALF OF CENTERS FOR MEDICAID AND MEDICARE SERVICES AND SOCIAL SECURITY ADMINISTRATION.

WE WILL NOT REFUSE YOU ANY BENEFITS OR ACCESS TO ANY PROGRAMS THAT YOU ARE ELIGIBLE SIMPLY BECAUSE YOU DO NOT GIVE US

PERMISSION TO OBTAIN, USE AND SHARE CONFIDENTIAL INFORMATION, HOWEVER, WE ARE UNABLE TO ASSIST YOU IN ACCESSING CERTAIN

PROGRAMS AND SUPPORTS THAT YOU MAY BE ELIGIBLE FOR IF WE DO NOT HAVE YOUR CONSENT TO OBTAIN AND SHARE INFORMATION.

YOUR CONSENT IS REQUIRED IN ORDER TO DETERMINE YOUR ELIGIBILITY.

YOU CAN PROCEED TO SHOP FOR AND PURCHASE HEALTH INSURANCE COVERAGE WITHOUT COMPLETING THIS CONSENT BY CONTACTING OUR

CONTACT CENTER AT 1-855-840-HSRI (4774), BUT IF YOU WOULD LIKE TO KNOW WHETHER YOU ARE ELIGIBLE FOR ANY FINANCIAL HELP

FOR THE PURCHASE OF COVERAGE, WHETHER YOU ARE ELIGIBLE FOR MEDICAID, IT WILL BE NECESSARY FOR YOU TO COMPLETE THIS

CONSENT.

ALL INFORMATION SHARING AND USE THAT YOU ARE AUTHORIZING BY CHECKING THE “I AGREE” BOX WILL BE DONE IN COMPLIANCE WITH

ALL RELEVANT FEDERAL AND STATE LAWS AND REGULATIONS PROTECTING YOUR PRIVACY, INCLUDING BUT NOT LIMITED TO: THE HEALTH

INSURANCE PORTABILITY AND ACCOUNTING ACT OF 1996 (PUB. L. 104-191 KNOWN AS HIPAA); THE R.I. CONFIDENTIALITY OF HEALTH

CARE COMMUNICATIONS AND INFORMATION (R.I.G.L. 5-37.3-1 ET SEQ.); R.I.G.L. 28-32-5, 28-36-12, 28-42-38, 28-39-19, 28-39-

22, 40.1-5-26, 23-3-23, 42-12-22, 40-6-12 AND ALL OTHER APPLICABLE LAWS AND REGULATIONS. INFORMATION WILL BE SHARED BY

COMPUTER DATA TRANSFER.

BY CHECKING ON THE I AGREE BOX “I CONSENT TO THE OBTAINING AND USE OF CONFIDENTIAL INFORMATION ABOUT ME TO DETERMINE MY

ELIGIBILITY FOR ENROLLMENT IN PUBLICLY FUNDED HEALTH INSURANCE COVERAGE OR OTHER PUBLICLY FUNDED PROGRAMS ADMINISTERED

THROUGH THIS SITE, PLAN, PROVIDE, AND COORDINATE BENEFITS AND PAYMENTS”.

I AGREE TO GIVE MY CONSENT TO SHARE DATA FOR ELIGIBILITY DECISIONS

I

DO NOT AGREE TO THIS

ONSENT AND UNDERSTAND THAT MY ELIGIBILITY FOR CERTAIN PROGRAMS AND SUPPORTS

DHS-2 Rev. 09-16

Application Page

of 32

WILL BE IMPACTED BY THIS DECISION

I HAVE READ OR HAD EXPLAINED TO ME MY RIGHTS AND RESPONSIBILITIES AND UNDERSTAND THAT I MAY KEEP A COPY OF THE RIGHTS AND

RESPONSIBILITIES (LISTED ON PAGES 28-32). YES NO

Please read the Rights and Responsibilities on the following pages

and SIGN Rights and

Responsibilities page 32. Your application must be signed to be a valid application.

For Certified Application Counselors, Navigators, Agents and Brokers Only

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for someone else.

Application Start Date: / /

Last Name First Name Middle Initial

Organization name

ID Number (if applicable)

DHS-2 Rev. 09-16

Application Page

of 32

For Applicant/Recipient Use Only

Use this page to add information about questions 1 through 44. Be sure to include the question number.

Question #_________ Page #__________

DHS-2 Rev. 09-16

Application Page 28 of 32

Rights and Responsibilities

RIGHTS AND RESPONSIBILITIES

Of Applicants/Recipients of RI Works Program (RIW), Supplemental Nutrition Assistance Program (SNAP), Medicaid and Private Health

Insurance with Financial Help, Child Care Assistance, General Public Assistance (GPA), RI SSI State

Supplemental Payment Program

(SSP)

RIGHTS

You have a RIGHT to request, and if found eligible, to receive financial or Medicaid or Supplemental Nutrition Assistance Program

benefits based on policies and standards established under State and Federal laws and regulations.

You have a RIGHT to appeal and to receive an administrative fair hearing if you disagree with any agency actions or if there are delays in

the process of your application. Hearings are the responsibility of the Executive Office of Health and Human Services Hearing Office, which

has been designated to serve as the appeal entity for all public-funded health and human services programs included in this application. If

you request an appeal, your hearing must be held promptly.

You may be represented by a lawyer or any other person you select to appear on

your behalf. For some programs, your benefits or services may be continued until a hearing decision is made if you appeal by certain

deadlines. See the chart below for details.

Program You must file an appeal in: Will benefits continue if the

appeal is made within 10 days of

the notice?

Medicaid/Private Health Insurance

with Financial Help

35 days after the notice date Yes

SNAP

90 days from the notice mail date

Yes

CCAP 30 days from the notice mail date Benefits may be reduced until a

hearing decision is made.

GPA 10 days from the notice mail date Yes, but request must be made in

writing

All other programs

30 days from the notice mail date

Yes

You have a RIGHT to non-discriminatory treatment. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA)

civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA

programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or

reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who

require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should

contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may

contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages

other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form

, (AD-3027)

found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide

in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed

form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence

Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:

program.intake@usda.gov. This institution is an equal

opportunity provider.

In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Section 504 of the Rehabilitation Act of 1973, as

amended

(29 U.S.C. 794), Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.), and Title IX of the Education Amendments

of 1972 (20

U.S.C. 1681 et seq.), the Food and Nutrition Act of 2008 (formerly the Food Stamp Act), the Age Discrimination Act of

1975, the U.S.

Department of Health and Human Services implementing regulations (45 C.F.R. Parts 80 and 84) and the U.S. Department

of Education

implementing regulations (34 C.F.R. Parts 104 and 106), and the U.S. Department of Agriculture, Food and Nutrition

Services (7 C.F.R. 272.6);

the EOHHS and the Department of Human Services (DHS), does not discriminate on the basis of race, color,

national origin, disability, religion,

political beliefs, age, religion or gender in acceptance for or provision of services, employment or treatment, in its education and other program

activities. Under other provisions of applicable law, EOHHS/DHS does not discriminate on the basis

of sexual orientation, gender identity or

expression. For further information about these non-discrimination laws, regulations and complaint procedures for resolution of complaints of

discrimination, contact

DHS at 206 El

mwood Avenue, Providence, RI 02907

telephone number 415-8500 (for deaf/hearing impaired 1-800-745-

6575 Voice; 1-800-745-5555 TTY, or 711). The Community Relations Liaison Officer is the coordinator

for implementation of Title VI, the

Office of Rehabilitation Services (ORS) Administrator or his/her designee is the coordinator for

implementation of the Title IX, Section 504, and

ADA. The Director of DHS or his/her designee has the overall responsibility for civil rights compliance for all agency programs. The Secretary

of EOHHS is responsible for Medicaid related discrimination issues and any such complaints will be referred accordingly.

You have a RIGHT to confidentiality. Under state law, all agencies administrating programs included as part of this application are bound

by state and federal laws and regulations to use information about you and other members of your household only for

purposes directly

related to the administration of the programs and in compliance of the Health Insurance Portability and

Accountability Act

(HIPAA) Standards for Privacy of Individually Identifiable Health Information. HIPAA restrictions prevent us

DHS-2 Rev. 09-16

Application Page 29 of 32

Rights and Responsibilities

from discussing the health information of you or any member of your household with anyone, including unauthorized representative, unless

that individual has power of attorney or you have signed a consent form authorizing the disclosure of this information. This includes disclosure

of mental health information, HIV, AIDS, STD test results or treatment and chemical dependency services.

I understand that by signing this application, I am giving the EOHHS and the DHS my consent to use or disclose protected health information

for the purposes of treatment, payment and health care operations in

accordance with applicable agency notices of privacy practices. The

EOHHS and DHS do not release information about you or other members of your household without your consent except as provided in

Rhode

Island General Laws 40-6-12, 40-6-12.1, and 42-7.2-5(13), regulations set forth in the DHS Administrative Code and Medicaid Codes of

Administrative Rules. Any person found

guilty of violating the provisions of Rhode Island General Laws 40-6-12 shall be deemed guilty of a

misdemeanor. Violators are subject

to a maximum fine of two hundred dollars ($200), or imprisonment of up to six (6) months, or both.

You have a RIGHT to file a joint application for more than one program or file a separate application for SNAP or Medicaid benefits without

applying

for other program benefits. All SNAP applications, regardless of whether they are joint applications or separate applications, must be

processed for SNAP and Medicaid purposes in accordance with procedural, timeliness, notice, and fair hearing requirements. No household shall

have its SNAP or Medicaid application denied solely on the basis that its application to participate in another program has been denied or its

benefits under another

program have been terminated without a separate determination by the appropriate agency that the household failed to

satisfy a SNAP or Medicaid eligibility

requirement. Households that file a joint application for SNAP and another program and are denied

benefits for the other program shall not

be required to resubmit the joint application or to file another application for SNAP, but shall have its

SNAP eligibility determined based on

the joint application in accordance with the SNAP processing time frames from the date the joint

application was accepted by the

Department.

You have a RIGHT to apply for support enforcement services through the Office of Child Support Services. To get an application for these

services, go to http://www.cse.ri.gov/

or visit your local Office of Child Support Services at 77 Dorrance St., Providence, RI 02903.

You have a RIGHT to name an authorized representative. An authorized representative is a person designated by the head of the household

or the spouse, or any other responsible member of the household, to act on behalf of the household in applying for program benefits, or

using the benefits. The authorized representative for benefits may or may not be the same individual designated as an authorized representative

for the application process or for meeting reporting requirements. The authorized representative designation must be made in writing.

If you are applying for Medicaid affordable health care coverage, the EOHHS requires that the Department must:

• Provide you with thirty (30) days to give us the information we need to review your eligibility. If you don’t give us the

information or ask for more time we may deny, close, or change your health care coverage.

• Notify you, in most cases, at least ten (10) days before we stop your health care coverage.

• Give you a written decision, in most cases, within thirty (30) days. Health care coverage and some disability cases may take forty-

five (45) to ninety (90) days.

• Continue Rhode Island Medicaid coverage while we decide if you are eligible under another program.

RESPONSIBILITIES

You have a RESPONSIBILITY to supply accurate information about your income, resources and living arrangements on this application.

You have a RESPONSIBILITY within ten (10) days for most programs and within thirty (30) days for Private Health Insurance with

Financial Help of any changes in your income, resources, family composition, or any other changes that affect your household. For Medicaid,

the ten (10) days begins five (5) days after the date the request for information was sent via email (transmittal date) or U.S. mail (postmark

date). If you don’t give us the information or ask for more time, we may deny, terminate suspend or change your health care coverage or

benefits. For RIW Cash and CCAP, you must tell us within five (5) days when a child leaves your household for any reason. For SNAP, if you

are a simplified reporter, you must report changes in income which bring the household's gross monthly income over the allowable amount for

your household size. If you are unsure about your reporting requirements, contact DHS for assistance.

You have a RESPONSIBILITY if you are applying for CCAP, to find a suitable child care provider for your child(ren) and to make

appropriate arrangements to have your child(ren) attend that provider. The Department of Human Services will pay only for those hours when

you are either at work or involved in a DHS approved education/training activity, and the cost of any child care in excess of those hours

is your

sole responsibility. If found eligible, you may be responsible for a share of the child care cost (co-payment) and you are responsible to make

such payment directly to your child care provider. If you are not found eligible, you have thirty (30) days from the written notice to request a

hearing in writing to appeal your ineligibility. If the decision of the hearing is not in your favor, DHS is not responsible for any of the child

care

costs that you may have incurred with your child care provider. By signing this form, you are authorizing the Department of Human

Services to

inform the child care provider(s) after you have been notified if your child care assistance has been approved, discontinued or

denied.

You have a RESPONSIBILITY to provide Social Security numbers (or proof that you have applied for one) for yourself and your

household, or to apply, if you are required to, for them as a condition of eligibility. The collection of information on the application, as

well

as the Social Security numbers of all members of your household for whom you receive assistance, is authorized under the Food

and

Nutrition Act of 2008 (formerly the Food Stamp Act), as amended, 7 U.S.C. 2011-2036 and under Federal Law (45 CFR 155.305

and 42 CFR 435.910). This information will be used to determine whether

your household is eligible or continues to be eligible to

participate in SNAP, Medicaid, RIW, GPA, CCAP, Private Health Insurance with Financial Help. The Department will verify this

information through computer matching with the Department of Labor and Training, the Social Security

DHS-2 Rev. 09-16

Application Page 30 of 32

Rights and Responsibilities

Administration, the Internal Revenue Service, the Food and Nutrition Service, and other governmental and non-governmental entities

authorized by law, regulation or contract, and they will be subject to verification by Federal, State, and local officials. The income and

eligibility information obtained from these agencies will be used to make sure your household is eligible for and receiving the correct

amount of SNAP benefits, GPA, Child Care, RIW, Medicaid, and Private Health Insurance with Financial Help. This information will

also be used to monitor compliance with program regulations, for program management as well as to prevent fraud and verify health

care claims.

Thi

s information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the

purpose of apprehending persons fleeing to avoid the law. If a claim arises against your household, the information on this application,

including all SSNs, may be referred to Federal and State agencies as well as private claims collection agencies for claims collection

action.

Providing the requested information is voluntary. However, failure to provide a SSN will result in the denial of benefits to any

individual applying for benefits. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household

members.

You have a RESPONSIBILITY to report and provide proof of your expenses shown in questions 38 through 42 in order to get the

maximum

amount of SNAP benefits allowed. Failure to report or provide proof of your expenses will be regarded as your statement

that you do not want

to receive a deduction for the unreported or unproven expense.

You have a RESPONSIBILITY to cooperate fully with state and federal personnel conducting quality control reviews.

Only U.S. citizens and certain legal immigrants may be eligible for SNAP benefits. If there are non-citizens living with you who are

not

eligible, you may still apply for and receive benefits for other eligible household members. You are not required to provide

immigration

information for people not applying for benefits, but you may need to provide other information for those people, such as,

income and resources.

You have a RESPONSIBILITY to cooperate with the Office of Child Support Services if you receive RI Works, Child Care Assistance or

Medicaid. You must help establish, modify, or enforce child support for the child(ren) in your care, and establish paternity (if necessary). If

you can show that you have a good reason to believe that cooperating with the Office of Child Support Services puts you, your children, or the

children in your care at risk of harm from the non-custodial parent, you may claim good cause not to cooperate.

You have a RESPONSIBILITY to apply for and make a reasonable effort to get potential income from other sources when you ask for or

receive RI Medicaid coverage.

Information about Private Health Insurance with Financial Help

If you have questions about the terms of your health insurance plan, including what benefits you are eligible for, out of pocket expenses under

your plan, and making a benefit claim or appealing a denial of benefits, you should contact your health insurance carrier. If you are eligible for

COBRA following the termination of any health insurance coverage, administering COBRA and providing you the required COBRA notices

and election periods is your former employer’s or issuer’s responsibility. Do not cancel any current insurance coverage or decline any COBRA

benefits until you receive an approval letter and insurance policy, also known as insurance contract or certificate, from the insurance carrier you

select. Make sure you understand and agree with the terms of the policy, pay special attention to the effective date, waiting periods, premium

amount, benefits, limitations, exclusions, and riders.

If you enroll in a private health insurance through HealthSource RI and you do not provide enough information for HealthSource RI to verify

your eligibility to purchase a plan or receive a reduced-cost plan, or if any information you provide is not verifiable, you will have ninety (90)

days to provide further information to satisfy HealthSource RI’s eligibility requirements. During this time, you should work with HealthSource

RI staff to try to provide any missing information or resolve any inconsistencies so that you may obtain coverage as soon as possible, or, if you

are provided conditional eligibility, you may avoid a disruption in coverage. If you enroll in private health insurance through HealthSource RI

and you have a change in income, you must notify HealthSource RI within thirty (30) days of that change. A change in income could change

the tax credits or cost-sharing reductions for which you are eligible to help you pay for insurance. We base your tax credit on the income you

put on this application. If your income goes up, you will qualify for less of a tax credit on your health coverage. If you don’t tell us about your

income changing, we will continue to offer the same discount every month but you may have to pay that money back at tax time.

Premium rates are subject to change based on the health insurance carrier’s underwriting practices and your selection of available optional

benefits, if any. Final rates are always determined by the health insurance carrier. Premium rates are for your requested effective date ONLY.

If the actual effective date of your policy is different from your requested effective date, the actual cost of your policy may differ from the rates

listed on healthsourceri.com, due to rate increases or policy changes from the insurance company and/or one or more family members having a

birthday. (Rates are highly dependent on age.) The carrier you selected may not guarantee their rates for any period of time until a contract is

signed.

RIW R

estrictions on Use of EBT Cash Benefits and Penalties: Pursuant to Section 4004 of Public Law 112-96, it is prohibited for

a TANF

recipient to use their TANF cash assistance benefits received under RI Works, Rhode Island General Laws 40-5.2 et seq., in

any electronic

benefit transfer transaction (EBT) in:

• any liq

uor store; or

• any casino, gambling casino, or gaming establishment; or

• any retail establishment which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed

state

for entertainment.

DHS-2 Rev. 09-16

Application Page 31 of 32

Rights and Responsibilities

Any person receiving cash assistance through the RI Works Program who uses an EBT card in violation of the above standards shall be subject to

the following penalties:

• For the first violation, the household will be sent a warning that a prohibited transaction occurred;

• For the second violation, the household will be charged a penalty in the amount of the EBT transaction that occurred at the

prohibited location;

• For the third and all subsequent violations, the household will be charged a penalty in the amount of the EBT transaction that

occurred at the p

rohibited location AND for the month following the month of infraction, the amount of cash assistance to

which an otherwise eligible recipient family is entitled shall be reduced by the portion of the family's benefit attributable to any

parent who utilized the EBT card in a restricted location. For a family size of two (2), the benefit reduction due to noncompliance

with use of E

BT at a restricted location shall be computed utilizing a family size of three (3), in which the parent’s portion equals to

one hundred

and five dollars ($105).

RIW/SNAP EBT Card Replacement Provisions:

Cardholders who request four (4) or more replacement EBT cards within a twelve (12) month period may be referred to the Fraud Unit

for investigation of misuse or abuse of the EBT card. Documented violations may result in one or more of the following actions:

• Disqualification fr

om the program;

• Recovery through recoupment/restitution; and/or

• Referral for criminal prosecution

In all cases, the agency shall act to protect households containing homeless persons, elderly or disabled members, victims of crimes, and other

vulnerable persons who may lose EBT cards but are not committing fraud.

RI WORKS PROGRAM, MEDICAID, CHILD CARE ASSISTANCE AND GENERAL PUBLIC ASSISTANCE

LIENS AND ASSIGNMENTS

I understand that pursuant to Rhode Island General Law, Sections 40-6-9, 40-6-10, or 40-8-15, without the necessity of signing any

document:

a.) Regarding Child Support and Establishment of Paternity

I have assigned any and all rights that I may have for and on behalf of myself, and for and on behalf of my child or children, to the

Department

of Human Services (DHS) and/or Executive Office of Health and Human Services (EOHHS), against any person failing to provide for support,

maintenance, and medical care for myself

and my minor child or children for whom assistance is paid by the DHS/EOHHS. The DHS/EOHHS

is authorized to perform the act of instituting suit to establish paternity and/or to collect support for myself or my child or children who receive

or received assistance from the DHS/EOHHS. If you stop getting cash or Medicaid, you must tell the Office of Child Support Services about any

changes that affect child/medical support such as if your child has moved or your address has changed.

b.)

Regarding Amounts Recoverable from a Third Party

I have assigned any and all rights to the DHS/EOHHS, for and on behalf of myself and any person for whom I may legally act, for amounts

recoverable from a third party equal to the amount of financial assistance and Medicaid provided as a result of accident, injury, or

illness.

c.) Regarding A

mounts Recoverable from Workers’ Compensation

The Department of Human Services and/or Executive Office of Health and Human Services may place a lien upon any pending award, order, or

settlement, which I may be entitled to under

the provisions of the Rhode Island Workers Compensation Act, Chapters 28-29 through 28-38 of

the Rhode Island General Laws. The

purpose of the lien is to secure reimbursement to the Department for financial and Medicaid payments

made to me or on my behalf for

the period of time for which my workers’ compensation award, order, or settlement is made.

d.) Regarding Lien on Deceased Recipient’s Estate for Medicaid Reimbursement

The DHS/EOHHS may place a lien upon the estate of a Medicaid recipient who was fifty-five (55) years of age or older at the time of death. For

purposes of this section the term "estate" with respect to a deceased individual shall include all real and personal property and other

assets included or includable within the individual's probate estate.

R.I.G.L. 40-8-15 provides that the total sum of Medicaid paid on behalf of a Medicaid recipient who was fifty-five (55) years of age or

older at

the time of receipt of such assistance shall be a debt to the state and shall constitute a lien upon the estate of the recipient in

favor of the DHS.

However, the lien shall not be effective and shall not apply to the estate of a recipient who is survived by a spouse,

or a child who is under the

age of twenty-one (21) or a child who is blind or permanently and totally disabled as defined in Title XVI

(SSI) of the Social Security Act.

Tribal lands and certain properties belonging to American Indians and Alaskan Natives may be exempt from recovery.

I understand that as a condition of receiving RIW benefits, all persons from whom I am requesting RIW, unless exempt by law, are

required to

comply with the RIW Program requirements.

I understand that this application will serve as authorization to the Department of Human Services to obtain from Medical providers

information

that is pertinent to me or any person included in this application for as long as the case remains open.

I understand and agree that the DHS office may contact other persons or organizations to obtain the necessary proof of my eligibility and level of

benefits.

SNAP PENALTY WARNINGS

I understand that:

Any member of my household who intentionally breaks a SNAP rule will be barred from the SNAP from one year to permanently,

fined

up to $250,000, imprisoned up to 20 years or both. S/he may also be subject to prosecution under other applicable Federal and

State

laws. S/he may also be barred from SNAP for an additional 18 months if court ordered. Any member of my household who

intentionally breaks a SNAP rule can be barred from the Supplemental Nutrition Assistance Program:

DHS-2 Rev. 09-16

Application Page 32 of 32

Rights and Responsibilities

• For a period of one (1) year for the first violation, with the exceptions in numbers 1. through 5. below;

• For a period of two (2) years after the second violation, with the exceptions in numbers 1. through 5. below; and,

• Permanently for the third occasion of any intentional program violation.

1. Individuals found by a Federal, State, or local court to have used or received SNAP benefits in a transaction involving the sale of

firearms, ammunitions or e

xplosives shall be permanently ineligible for the Supplemental Nutrition Assistance Program upon the first

occasion of such violation.

2. Individuals found to have made a fraudulent statement or representation with respect to the identity or place of residence of the

individual in ord

er to receive multiple SNAP benefits simultaneously shall be ineligible to participate in the Supplemental Nutrition

Assistance Program for a period of ten (10) years.

3. Individuals found guilty by a Federal, State or local court of law for using or receiving benefits in a transaction involving the sale of

controlled substance (as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)) will not be eligible for benefits for

two

years for the first offense, and permanently for the second offense.

4. Individuals found guilty by a court of law for buying or selling illegal drugs or certain prescription drugs in exchange for SNAP

benefits will be pr

ohibited from participating in the SNAP for 24 months for the first offense and permanently for the second offense.

5. An individual convicted by a Federal, State, or local court of having trafficked benefits for an aggregate amount of $500 or more shall

be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.

Trafficking as defined in 7 CFR 271.2 means:

1) Buying, selling, stealing or attempting to buy, sell, steal, or otherwise effect an exchange of SNAP benefits issued and accessed via

Electronic Benefit Transfer (EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and

signature, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or

acting alone;

2) The exchange of firearms, ammunition, explosives, or controlled substances for SNAP benefits;

3) Purchasing a product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining cash by discarding

the product and returning the container for the deposit amount, intentionally discarding the product, and intentionally returning the

container for the deposit amount;

4) Purchasing a product with SNAP benefits with the intent of obtaining cash or consideration other than eligible food by reselling the

product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for cash or consideration

other than eligible food; or

5) Intentionally purchasing products originally purchased with SNAP benefits in exchange for cash or consideration other than eligible

food.

DO NOT lie or hide information to get or continue to get SNAP benefits that your household should not get.

DO NOT use SNAP benefits to buy non-food items, such as alcoholic drinks and cigarettes or to pay on credit accounts.

DO NOT trade or sell (or attempt to trade or sell) EBT cards or use someone else’s EBT card for your household.

DHS can use or share information on this application for the administration of DHS programs, as well as the administration of other federally

funded assistance programs in accordance with state and federal law, contract and regulation.

DHS can release non-identifying information for research purposes. Any release of identifying information shall be done in accordance with

state and federal law.

I understand the questions on this application and the penalty for hiding or giving false information or breaking any of the rules listed in this

penalty warning.

I certify under penalty of perjury that my answers are correct, including information about citizenship and alien status, and

complete to the best of my knowledge and belief. I know that under the state of Rhode Island General Laws, Section 40-6-15, a maximum fine

of $1,000, or imprisonment of up to five (5) years, or both, may be imposed for a person who obtains or attempts to obtain, or aids or abets any

person to obtain, public assistance to which s/he is not entitled, or who willfully fails to report income, resources or personal circumstances or

increases therein which exceed the amount previously reported. I attest to the identity of the minor children identified herein and 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 Spouse or other parent of child(ren)

Date

Signature of Person Helping you Complete this Form

Date

Signature of Guardian, Conservator or Holder of

Power of Attorney

Date

Signature of Agency Representative

Date

FOR AGENCY USE ONLY

Withdrawal of Application

After participating in the screening interview, I do not wish to make an application for RIW, SNAP, EAD, LTSS, ACC, 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 you application:___________________________________________________________________

_________________________________________________ _________________________

Applicant’s signature Date

Agency Representative Name:_____________________________________ Signature:______________________________________________

COMMENTS

INITIALS

DATE

Notice to Applicant

Registering to Vote in Rhode Island

The State Board of elections urges all of its citizens to register to vote. Your vote

will benefit you and your family.

Included in this packet of forms is a voter registration form. If you would to

Canvassers. (directory listed on the back of the form)

• If you are not registered to vote where you live today, complete the

enclosed form.

• Applying to register or declining to register to vote will not affect the

amount of assistance provided by this agency.

• If you would like help in completing the voter registration application form,

you can bring it with you when you return the other completed forms in this

package, or go to the local Board of Canvassers in the city/town where

you live. (City/Town directory is on the back of the voter registration form.)

The decision whether to seek or accept help is yours.

• If you believe that someone has interfered with your right to register or

decline to register to vote, your right to privacy in deciding whether to

political party or other political preference, you may file a complaint with

the Voter Registration Coordinator, 50 Branch Avenue, Providence, RI

02904 or (401)222-2345.

Eligibility

If you check “No” in response

to any of these questions, do not

complete this form.

Personal Information

All elds on this form are required

except when indicated as optional.

Phone/email is optional and is

public record.

Identication Numbers

If you have never voted in

Rhode Island, please enter the

appropriate identication number.

Driver’s License and State ID card

must be issued by the

RI Division of Motor Vehicles.

You may also submit a copy of

your identication with this

application.

Rhode Island

Home Address

Mailing Address

If dierent from

Rhode Island Home Address.

Party Aliation

Armation

and Signature

Update my Information

If you have changed your name or

were already registered to vote in

RI or in another state.

Get Involved!

Last Name Sux

First Name Middle Initial

Date of Birth (mm/dd/yyyy) Phone/Email (optional)

Previous Name

Previous Address (County, City/Town, State, Zip Code)

I am interested in being a poll worker

I swear or arm that:

I am a U.S. Citizen; I live at the address set forth above; I will be at least eighteen (18) years old

when I vote; I am not incarcerated in a correctional facility upon a felony conviction; I have not

been lawfully judged “mentally incompetent” to vote by a court of law. The information I have

provided is true to the best of my knowledge under pains and penalty of perjury. If I have provided

false information, I may be ned, imprisoned, or (if not a U.S. citizen) deported from or refused

entry into the United States.

SIGN HERE:

Rhode Island

Voter Registration Form

This form is for: New voter Update my information Party change

Are you a citizen of the United States? Yes No

Are you a resident of Rhode Island? Yes No

Are you at least 16 years of age? Yes No

Home Address (Not a PO Box) Unit Number

City/Town State Zip Code

Democrat Republican Unaliated Other: ___________________

Rhode Island Driver’s License or State ID card number:

__________________________

I have not been issued a RI Driver’s License or State ID card.

Enter the last 4 digits of your Social Security Number (SSN): ______ ______ ______ ______

I have not been issued a RI Driver’s License, State ID card, or a Social Security Number.

You must be 18 years old to vote.

Mailing Address Unit Number

City/Town State Zip Code

Ocial use for barcode

Date Signed

(mm/dd/yyyy)

Warning: If you sign this

form and know it to be false,

you can be convicted and

ned up to $5,000 or jailed

up to 10 years.

Barrington Town Hall

283 County Rd. 02806

247-1900 x4

Bristol Town Hall

10 Court St. 02809

253-7000

Burrillville Town Hall

105 Harrisville Main St.

Harrisville 02830

568-4300

Central Falls City Hall

580 Broad St. 02863

727-7450

Charlestown Town Hall

4540 South County Trl. 02813

364-1200

Coventry Town Hall

1670 Flat River Rd. 02816

822-9150

Cranston City Hall

869 Park Ave. 02910

780-3126

Cumberland Town Hall

45 Broad St. 02864

728-2400

East Greenwich Town Hall

125 Main St.,

P.O. Box 111 02818

886-8603

East Providence City Hall

145 Taunton Ave. 02914

435-7502

Exeter Town Hall

675 Ten Rod Rd. 02822

294-2287

Foster Town Hall

181 Howard Hill Rd. 02825

392-9201

Glocester Town Hall

1145 Putnam Pike

P.O. Box B, Chepachet 02814

568-6206 x0

Hopkinton Town Hall

1 Town House Rd. 02833

377-7777

Jamestown Town Hall

93 Narragansett Ave. 02835

423-9804

Johnston Town Hall

1385 Hartford Ave. 02919

553-8856

Lincoln Town Hall

100 Old River Rd.

P.O. Box 100 02865

333-1140

Little Compton Town Hall

40 Commons

P.O. Box 226 02837

635-4400

Middletown Town Hall

350 East Main Rd. 02842

849-5540

Narragansett Town Hall

25 Fifth Ave. 02882

782-0625

Newport City Hall

43 Broadway 02840

845-5386

New Shoreham Town Hall

16 Old Town Rd.

P.O. Box 220 02807

466-3200

North Kingstown Town Hall

100 Fairway Dr, 02852

294-3331 x128

North Providence Town Hall

2000 Smith St. 02911

232-0900 x234

North Smitheld

Municipal Annex

575 Smitheld Rd. 02896

767-2200

Pawtucket City Hall

137 Roosevelt Ave. 02860

722-1637

Portsmouth Town Hall

2200 East Main Rd. 02871

683-3157

Providence City Hall

25 Dorrance St. 02903

Room 102

421-0495

Richmond Town Hall

5 Richmond Townhouse Rd.

Wyoming 02898

539-9000 x9

Scituate Town Hall

195 Danielson Pike

P.O. Box 328

North Scituate 02857

647-7466

Smitheld Town Hall

64 Farnum Pike, 02917

233-1000 x116

South Kingstown Town Hall

180 High St.

Wakeeld 02879

789-9331 x1231

Tiverton Town Hall

343 Highland Rd. 02878

625-6703

Warren Town Hall

514 Main St. 02885

245-7340

Warwick City Hall

3275 Post Rd. 02886

738-2010

West Greenwich Town Hall

280 Victory Hwy. 02817

392-3800

West Warwick Town Hall

1170 Main St. West Warwick, RI

02893

822-9201

Westerly Town Hall

45 Broad St. Westerly, RI 02891

348-2503

Woonsocket City Hall

169 Main St.

P.O. Box B 02895

767-9221

Return Address

__________________________________________

Mail to: BOARD OF CANVASSERS

____________________________________________

Postage

Required

Post Oce

will not deliver

without proper

postage.