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DHS-* Rev. **-** Instructions Page * of *

RHODE ISLAND DEPARTMENT OF HUMAN SERVICES

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-***-****).

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 2 of 4

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 Identification

Immigration and Naturalization Documents (e.g., Green Card)

Hospital birth records

Birth Certificates

U.S. Passport

Any other documentation requested for citizenship, immigration status, or age may be used for verification of identity 2. To verify your Rhode Island residence (All Programs except ACC, unless questionable)

Rent or mortgage receipts showing address Lease agreement of letter from landlord

Library card showing address Mail received with your home address (utility bills, bank statements)

Voter’s registration 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 Administration (VA) benefits.

Previous tax returns

Social Security, Supplemental Security Income, or Veteran’s Benefits award letter

Proof of self-employment income (includes rental income and freelance work): provide tax returns or self-employment ledger

Other retirement or disability benefit award letters Child Support court order 4. To verify your resources (RIW, GPA, EAD, LTSS, MPP, SSP, KB, CCAP if over $9,500)

Documentation of ownership of a trust Vehicle registration including car, boat, truck, motorcycle, camper

Proof of rental properties 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 utility 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 Retirement, Survivors, and Disability Insurance (RSDI) or Supplemental Security Income (SSI); copy of the award letter or similar documentation from the Social Security Administration and/or current finding of eligibility for RSDI or SSI based on blindness

Copy of medical examination report on file at the Office of Rehabilitation Services (ORS), Services for the Blind and Visually Impaired

Statement from a medical professional

DHS-2 Rev. 09-16 Instructions Page 3 of 4

ABOUT THE PROGRAMS

Again, 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-***-****). DHS-2 Rev. 09-16 Instructions Page 4 of 4

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-***-****. 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 for 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-***-****) if you need more information about which pathway is best for you.

DHS-2 Rev. 09-16 Application Page 1 of 32

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) KB 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 2 of 32

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? HOUSEHOLD 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 No

Yes No

Yes No

Yes No

Yes No

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)

D HS-2 Rev. 09-16 Application Page 3 of 32

1

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

2

Is any applicant getting benefits/receiving assistance in another state? YES NO If, YES, Who? Which State? 3

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 KB

RIW SNAP CCAP GPA SSP ACC LTSS EAD MPP KB

SNAP

DHS-2 Rev. 09-16 Application Page 4 of 32

4

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: 5

Is any applicant imprisoned (detained or jailed)? YES NO If, YES, Who? Which facility? Date of imprisonment: Date of release 6

Was any applicant in the care and custody of the RI Department of Children, Youth and Families on his/her 18th birthday? YES NO If, YES, Who? 7

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 8

Is any applicant a honorably discharged veteran or active duty member of the military? Yes No If, YES, Who? 9

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 10

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 KB

ACC

RIW CCAP GPA SSP ACC LTSS EAD MPP KB

RIW SNAP ACC LTSS EAD MPP KB

RIW SNAP ACC LTSS EAD MPP KB

ACC

DHS-2 Rev. 09-16 Application Page 5 of 32

11

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

12

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 Last Name First Name Middle Initial 13

A 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

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