Fillable Commonwealth of Massachusetts SNAP Application Seniors English

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Commonwealth of Massachusetts SNAP Application Seniors English

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HowdoIapplyforSNAPbenefits?

 Bymailingthisapplicationto:

DTADocumentProcessingCenter

P.O.Box4406

Taunton,MA02780‐0420

 Byfaxingthisapplicationto:

(617) 887‐8765

 BygoingintoanylocalDTAoffice

Makesurethatyou:

 Giveusaphonenumberwherewecancallyouduri

ngweekdays.

 Answerasmanyquestionsasyoucan.Ifyouaren’tsurehowto

answeraquestion,leaveitblankandwewilltalkaboutitduringyour

interview.Wewillacceptyourapplicationifithasyourname,

address(ifany)andsignature.

 ReadtheNoticeofRights,ResponsibilitiesandPenalties.

 Signyournameonthelastpage.

Ifyouwantmoreinformationorneedhelppleasecall1‐833‐712‐8027or

visitourwebsiteatwww.mass.gov/dta.

WhathappensafterIapply?

Wewillcallyouforaninterviewtotalkaboutyourapplication.

 Ifwecannotreachyou,wewillmailyoualetterforascheduled

phoneinterview.

Note:Letusknowifyoucan’tkeepthescheduledintervieworifyou

prefertocometoDTAfortheinterview.Youcancallusforthe

interviewatanytimeduringbusinesshours.

 WewillprovideyouaninterpreterifyoudonotspeakEnglish.

Seenextpageformoreinformation.Keepthissheetforyourrecords.

SupplementalNutritionAssistanceProgram(SNAP)

ApplicationforSeniors

(Forindividualsandcou

lesa

e60orolder)

i

SNAP‐App‐Seniors(Rev.9/2018)

09‐160‐0918‐05

Wemayneedverification(proof)ofsomeofthethingsyoutellus.Duringthe

interviewwewilltellyouwhatverificationsweneed.Wewillalsomailyoua

list.Youhave30daysfromthedatewegetyourapplicationtogiveusthe

verificationsweneed.Besuretotellusifyouneedhelp!

Wemayaskfor:

 Identity(whoyouare)

 VerificationthatyouareaMassachusettsresident

 Yourincome:Earningsorself‐employment,Veterans’benefitsora

pension

 Non‐citizenstatusifyouareanon‐citizenapplyingforSNAP

 Medicalcosts(thisisnotrequiredbutmaymakeyoueligibleformore

SNAPbenefitsifyougiveusverification)

Ifyoutellusaboutyourshelteroradultdaycarecostsonthisapplication,we

maynotneedtoaskyouformoreverification.

WewillalsomailyouanElectronicBenefitTransfer(EBT)cardifyouneedone.

YoumaygettheEBTcardbeforewedecideifyouareeligibleforbenefits.You

willalsoreceiveaPersonalIdentificationNumber(PIN)tousewithyourEBT

card.Thisissoyoucanuseyourbenefitsassoonastheyareavailable,ifyou

areeligible.WhenyougetyourEBTcard,youwillalsogetmoreinformationon

howtouseit.

Wewillmakeadecisionaboutyourapplicationandmailyoualetterwithin

30days.Ifweapproveyourapplication,wewilltellyouyourbenefitamount

andwhenyouwillgetyourbenefits.Ifwedenyyourapplication,wewilltell

youwhy.

Seenextpageformoreinformation.Keepthissheetforyourrecords.

iiSNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

MassachusettsDepartmentofTransitionalAssistance

SNAPApplicationforSeniors

(Forindividualsandcouplesage60orolder)

YoumaygetSNAPbenefitswithin7daysifoneofthefollowingdescribesyou:

 Doesyourincomeandmoneyinthebankadduptolessthanyourmonthlyhousing

expenses(includingutilities)?

Yes No

 Isyourmonthlyincomelessthan$150andisyourmoneyinthebank$100orless?

Yes No

 Areyouamigrantworkerandisyourmoneyinthebank$100orless?

Yes No

Informationaboutyou

LastName FirstName MiddleInitial SocialSecurityNumber

Whatisthebestphonenumbertoreachyou:

Male Female

Agoodtimeofdaytoreachyoubyphone:

Time: Morning Afternoon

Checkallthatapply:

Monday Tuesday Wednesday Thursday Friday

DateofBirth:

HomeAddress Areyouhomeless?

Yes No

City,State,ZipCode

MailingAddress(ifdifferent):

Whatisyourprimarylanguage?

1SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

1. YourEthnicity/Race:Weaskforthisinformationtomakesurewetreateveryonefairly.

Youranswerisvoluntary,anditwillnotaffectyoureligibilityorbenefitamount.

Ethnicity:Hispanic orLatino

Yes No

Race:(checkallapplicable)

AmericanIndianorAlaskaNative Asian

BlackorAfricanAmerican White

NativeHawaiianorOtherPacificIslander

2. AreyouaU.S.citizen?

Yes No

3. AreyouaresidentofMassachusetts?

Yes No

4. Doyouneedhelpbecauseofadisability?Wecangiveyouextrahelpcalled

accommodations.Accommodationscanmakeworkingwithuseasier.

Yes No

5. Doyouoranyoneinyourhouseholdhavemilitaryexperience?

Yes No

Informationaboutyourhousehold

6. Dootherpeoplelivewithyou?

Yes No

Ifyes,doyousharemealsmo rethanhalfofthetime?

Yes No

7. Listthepeoplewholivewithyou. YoudonotneedtogiveustheSocialSecurityNumber

orcitizenshipstatusfornoncitizenswhoarenotapplyingforSNAP,eveniftheylivewith

you.

LastName FirstName MiddleInitial

Male Female

Whatisthisperson’srelationshiptoyou? DateofBirth:

U.S.Citizen? Yes No

SocialSecurityNumber

LastName FirstName MiddleInitial

Male Female

Whatisthisperson’srelationshiptoyou? DateofBirth:

U.S.Citizen? Yes No

SocialSecurityNumber

2SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

FinancialInformation

8. Tellusaboutyourincomeandtheincomeofanyonewholiveswithyou.

TypeofIncome Amount Frequencyofincome

(weekly,bi‐weekly,

monthly,etc.)

Whoseincomeisthis?

SocialSecurity $ monthly

SSI $ monthly

Pension $

Veterans’Benefits $

Workers’Compensation $

Wagesfrom

employment

$

Unemployment $

Other(specify) $

9. Doyouneedtopayforadultdependentcarecosts? Yes No

Ifyes,howmuchdoyouneedtopayfor?_________per_____________(week,

month,year,etc.)

10. Doyoudr ivetoandfromadultdependentcare?

Yes No

Ifyes,addressofthecareprovider______________________________________

Numberoftimes___________________(week,month,year,etc.)

11. Doyouneedtopayforoutofpocketmedicalcosts?

Yes No

Thiscanincludeco‐pays,prescriptions,over‐the‐countermedicines,eyeg lasses,dental

care,hearingaidbatteries,etc.

12. Doyoudr ivetoandfromthedoctororpharmacy?

Yes No

Ifyes,addressofthedoctororpharmacy_____________________________________

Numberoftimes___________________(week,month,year,etc.)

3

SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

Doyouneedtopayforparking,$____________per_____________(week,month,

year,etc.)

13. Doyouneedtopayforrent?

Yes No

Ifyes,howmuchdoyouneedtopayfor:

Rent$______________per_____________(week,month,year,etc.)

14. Doyouownyourhome?

Yes No

Ifyes,howmuchdoyouneedtopayfor:

Mortgage $____________per_______________(month,year,etc.)

PropertyInsurance $____________per_______________(month,year,etc.)

PropertyTaxes $____________per_______________(month,year,etc.)

CondoFee $____________per_______________(month,year,etc.)

15. Doyouneedtopayforanyofthefollowing?

 Heat(oil,gas,electricityorpropane,etc.)

Yes No

 Electricityforanairconditioner

Yes No

 Afeetouseanairconditioner

Yes No

 Electricityand/orgas

Yes No

 Phoneorcellservicephoneservice

Yes No

ReleaseofInformationforAssistingPersonorOrganization

16. IsanyonehelpingyouapplyforSNAPbenefits?WecallthisanAssisting

Person/Organization.

Yes No

DoyouwanttogivethispersonororganizationpermissiontospeaktoDTAandshare

relevantconfidentialinformationaboutyourcaseforuptooneyearfromthedatethis

applicationissigned? 

Yes No

Ifyes,pleaselisttheirinformationbelow:

NameofPersonorOrganization: PhoneNumberofPersonorOrganization:

_____________________________ _________________________________

4

SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

AddressofPersonorOrganization:

___________________________________________________

NOTE:AnAssistingPersonmustnotcompletetheapplicationinterviewonbehalfof

yourhousehold.

AuthorizedRepresentative

17. Doyouwanttogivesomeonepermissionto:

 Signtheapplicationandotherforms,reportchanges,andtalkaboutyourcasewith

us?   

Yes No

 GetanEBTcardthatletsherorhimshopforyouusingyourSNAPbenefits?

Yes No

Wecallthispersonanauthorizedrepresentative.Ifyouansweryes,pleaselisttheir

informationbelow.

LastName FirstName MiddleInitial

Male Female

Whatisthisperson’srelationshiptoyou? DateofBirth:

Phonenumberofthisperson

Addressofthisperson

Signatureofthisperson

Important:Thepersonyouchoosemustgiveusproofofidentity.Youcancancelorchange

thisrequestatanytime.EBTcardsstillworkifacasereopensafterbeingclosed.Ifyou

don’twantthepersonyouchoosetogetanduseyourbenefitsbesuretotellustocancel

yourcard.Call1‐800‐997‐2555tocancelyourEBTcardor1‐833‐712‐8027tocancelan

AuthorizedRepresentative.

5SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

NoticeofRights,ResponsibilitiesandPenalties–PleaseReadCarefully

IcertifythatIhaveread,orhavehadreadtome,theinformationinthisapplication.Myanswerstothe

questionsinthisapplicationaretrueandcompletetothebestofmyknowledge.Ialsocertifythatinformation

IprovidetotheDepartmentduringtheapplicationinterviewandinthefuturewillalsobetrueandcomplete

tothebestofmyknowledge.Iunderstandthatgivingfalseormisleadinginformationisfraud.Ialso

understandthatmisrepresentingorwithholdingfactstoestablishSNAPeligibilityisfraud.Thisresultsinan

IntentionalProgramViolation(IPV)andispunishablebycivilandcriminalpenalties.

IunderstandthattheDepartmentofTransitionalAssistance(DTA)administersSNAP.IunderstandthatDTA

has30daysfromthedateofapplicationtoprocessmyapplication.Further,Iunderstandthat:

 TheFoodandNutritionActof2008(7U.S.C.2011‐2036)allowsDTAtousemySocialSecurityNumber

(SSN)andtheSSNofeachhouseholdmemberIapplyfor.DTAusesthisinformationtodeterminemy

household’seligibilityforSNAP.DTAverifiesthisinformationthroughcomputermatchingprograms.I

understandthatDTAusesittomonitorcompliancewithprogramregulations.

 Mostofthetime,householdsundertheSNAPSimplifiedReportingruleshavetotellDTAchangesat

InterimReport(IR)andrecertificationwiththeexceptionof:

o Ifmyhousehold’sincomeexceedsthegrossincomethreshold

o IfIamundertheable‐bodiedadultwithoutdependents(ABAWD)workrequirementsandmy

workhoursdropbelow20hoursweekly

 IfDTAreceivesverifiedinformationaboutmyhousehold,mybenefitamountmaychange

 IfIamnotundertheSNAPSimplifiedReportingrulesorTransitionalBenefitsAlternative(TBA)rules,I

mustreporttoDTAchangestomyhouseholdthatmayaffectoureligibility.IunderstandthatImust

reportthesechangestoDTAinperson,inwritingorbyphonewithin10daysofthechange.For

example,youmustreportchangesinyourhousehold’sincome,size,oraddress.

 IhavearighttospeaktoasupervisorifDTAfindsmeineligibleforemergencySNAPbenefitsandI

disagree.ImayspeaktoasupervisorifIameligibleforemergencySNAPbenefitsbutdonotgetmy

benefitsbytheseventhcalendardayafterIappliedforSNAP.ImayspeaktoasupervisorifIam

eligibleforemergencySNAPbenefitsbutdonotgetmyElectronicBenefitTransfer(EBT)cardbythe

seventhcalendardayafterIappliedforSNAP.

 ImayreceivemoreSNAPbenefitsifIreportandgiveverificationtoDTAof:

o childorotherdependentcarecosts,sheltercosts,and/orutilitycosts

o legally‐obligatedchildsupporttoanonhouseholdmember

 IfIam60yearsorolderorifIamdisabledandIpayformedicalcosts,Icanreportandgiveverification

ofthesecoststoDTA.ThismaymakemeeligibleforadeductionandincreasemySNAPbenefits.

 Unlesstheymeetanexemption,allSNAPrecipientsbetweentheagesof16and59areworkregistered

andsubjecttoGeneralSNAPWorkRequirements.SNAPrecipientsbetweentheagesof18and49may

alsobesubjecttotheABAWDWorkProgramrequirements.DTAwillinformnonexempthousehold

membersoftheworkrequirements.DTAwillinformnonexempthouseholdmembersofexceptions

andpenaltiesfornoncompliance.

 MostSNAPrecipientsmayvoluntarilyparticipateineducationandemploymenttrainingservices

throughtheSNAPPathtoWorkprogram.DTAwillgivereferralstotheSNAPPathtoWorkprogramif

appropriate.

6

SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

 DTAmayalsosharethenamesandcontactinformationofSNAPrecipientswithSNAPPathtoWork

providersforrecruitmentpurposes.Iunderstandthatmembersofmyhouseholdmaybecontactedby

DTASNAPPathtoWorkspecialistsorcontractedproviderstoexploreSNAPPathtoWorkparticipation

options.FormoreinformationabouttheSNAPPathtoWorkprogram,visitwww.snappathtowork.org.

IunderstandthattheinformationIgivewithmyapplicationwillbesubjecttoverificationtodetermineifit

istrue.Ifanyinformationisfalse,DTAmaydenymySNAPbenefits.Imayalsobesubjecttocriminal

prosecutionforprovidingfalseinformation.

IunderstandthatbysigningthisapplicationIgiveDTApermissiontoverifyandinvestigatetheinformationI

givethatrelatestomyeligibilityforSNAPbenefits,includingpermissionto:

 Getdocumentstoproveinformationonthisapplicationwithotherstateagencies,federalagencies,

localhousingauthorities,out‐of‐statewelfaredepartments,financial institutionsandfromEquifax

WorkforceSolutions.IalsogivepermissiontotheseagenciestogiveDTAinformationaboutmy

householdthatconcernsmySNAPbenefits.

 Ifapplicable,verifymyimmigrationstatusthroughtheUnitedStatesCitizenshipandImmigration

Services(USCIS).IunderstandthatDTAmaycheckinformationfrommySNAPapplicationwithUSCIS.

AnyinformationreceivedfromUSCISmayaffectmyhousehold’seligibilityandamountofSNAP

benefits.

 Shareinformationaboutmeandmydependentsunderage19withtheDepartmentofElementaryand

SecondaryEducation(DESE).DESEwillcertifymydependentsforschoolbreakfastandlunchprograms.

 Shareinformationaboutme,mydependentsunderage5andanyonepregnantinmyhouseholdwith

theDepartmentofPublicHealth(DPH).DPHreferstheseindividualstotheWomen,Infantsand

Children(WIC)Programfornutritionservices.

 Shareinformation,alongwiththeMassachusettsExecutiveOfficeofHealthandHumanServices,about

myeligibilityforSNAPwithelectriccompanies,gascompaniesandeligiblephoneandcablecarriersto

certifymyeligibilityfordiscountutilityrates.

 SharemyinformationwiththeDepartmentofHousingandCommunityDevelopment(DHCD)forthe

purposeofenrollingmeintheHeat&EatProgram.

DTAmaydeny,stoporlowermybenefitsbasedoninformationfromEquifaxWorkforceSolutions.Ihavethe

righttoafreecopyofmyreportfromEquifaxifIrequestitwithin60daysofDTA’sdecision.Ihavetherightto

questiontheaccuracyorcompletenessoftheinformationinmyreport.ImaycontactEquifaxat:Equifax

WorkforceSolutions,11432LacklandRoad,St.Louis,MO63146,1‐800‐996‐7566(tollfree).

IunderstandthatIwillgetacopyofthe“YourRighttoKnow”brochureandtheSNAPProgrambrochure.Iwill

readorhavereadtomethebrochuresandImustunderstandtheircontentsandmyrightsand

responsibilities.IfIhaveanyquestionsaboutthebrochuresoranyofthisinformation,IwillcontactDTA.IfI

havetroublereadingorunderstandinganyofthisinformation,IwillcontactDTA.DTAcanbereachedat:1‐

877‐382‐2363.

IswearthatallmembersofmySNAPhouseholdrequestingSNAPbenefitsareeitherU.S.citizensorlawfully

residingnoncitizens.

7

SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

RighttoRegistertoVote

IunderstandIhavetherighttoregistertovoteatDTA.IunderstandthatDTAwillhelpmefilloutthevoter

registrationapplicationformifIwanthelp.Iamallowedtofilloutthevoterregistrationapplicationformin

private.

IunderstandthatapplyingtoregisterordecliningtoregistertovotewillnotaffecttheamountofbenefitsI

getfromDTA.

SNAPPenaltyWarning

IunderstandthatifIoranymemberofmySNAPhouseholdintentionallybreaksanyoftheruleslistedbelow,

thatpersonwillnotbeeligibleforSNAPforoneyearafterthefirstviolation,twoyearsafterthesecond

violationandforeverafterthethirdviolation.Thatpersonmayalsobe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.

Theserulesare:

 DonotgivefalseinformationorhideinformationtogetSNAPbenefits.

 DonottradeorsellSNAPbenefits.

 DonotalterEBTcardstogetSNAPbenefitsyouarenoteligibletoget.

 DonotuseSNAPbenefitstobuyineligibleitems,suchasalcoholicdrinksandtobacco.

 Donotusesomeoneelse’sSNAPbenefitsorEBTcard,unlessyouareanauthorizedrepresentative.

Ialsounderstandthefollowingpenalties:

 IndividualswhocommitacashprogramIntentionalProgramViolation(IPV)willbeineligibleforSNAPfor

thesameperiodtheindividualisineligiblefromcashassistance.

 IndividualswhomakeafraudulentstatementabouttheiridentityorresidencytogetmultipleSNAP

benefitsatthesametimewillbeineligibleforSNAPfortenyears.

 Individualswhotrade(buyorsell)SNAPbenefitsforacontrolledsubstance/illegaldrug(s),willbeineligible

forSNAPfortwoyearsforthefirstfinding,andforeverforthesecondfinding.

 Individualswhotrade(buyorsell)SNAPbenefitsforfirearms,ammunitionorexplosives,willbeineligible

forSNAPforever.

 Individualswhotrade(buyorsell)SNAPbenefitshavingavalueof$500ormore,willbeineligibleforSNAP

forever.

 TheStatemaypursueanIPVagainstanindividualwhomakesanoffertosellSNAPbenefitsoranEBTcard

onlineorinperson.

 Individualswhoarefleeingtoavoidprosecution,custodyorconfinementafterconvictionforafelony,or

areviolatingprobationorparole,areineligibleforSNAP.

 PayingforfoodpurchasedoncreditisnotallowedandcanresultindisqualificationfromSNAP.

 IndividualsmaynotbuyproductswithSNAPbenefitswiththeintenttodiscardthecontentsandreturn

containersforcash.

RighttoanInterpreter

IunderstandthatIhavearighttoaninterpreterprovidedbyDTAifnoadultinmySNAPhouseholdisableto

speakorunderstandEnglish.IalsounderstandthatIcangetaninterpreterforanyDTAfairhearingorbring

oneofmyown.IfIneedaninterpreterforahearing,ImustcalltheDivisionofHearingsatleastoneweek

beforethehearingdate.

8

SNAP-App-Seniors (Rev. 9/2018)

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NondiscriminationStatement

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.



APPLICANT’S SIGNATURE:Bysigningthisapplication,IcertifythatIunderstandand

agreetothe“Rights,ResponsibilitiesandPenalties.”

ApplicantSignature:_______________________________________________

Date:____________________

9SNAP-App-Seniors (Rev. 9/2018)

09-160-0918-05

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Commonwealth of Massachusetts SNAP Application Seniors English

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Completed 16 May 2020

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