Fillable Commonwealth of Massachusetts SNAP Benefits Application

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Commonwealth of Massachusetts SNAP Benefits Application

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The Commonwealth of Massachusetts SNAP Benefits Application form is 16 pages long and contains:

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  • 104 check-boxes
  • 172 other fields

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File type: PDF

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Massachusetts Department of Transitional Assistance
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FSA-1
Things you must provide, if they apply to you, to receive SNAP benefits
1. Proof of Identity: Driver’s license, bir
th certificate or other proof of your identity.
2. Proof of Massachusetts Residence: Current rent receipt, lease, mortgage statement, tax document,
homeowner’s insurance or utility bills. If you are homeless, a motor vehicle registration, statement from a
shelter, from the person you are staying with temporarily, or a verbal or written confirmation from
someone we can contact who knows your situation.
3. Earned Income: Pay stubs or written statement from employer on letterhead showing income before
taxes for the past four weeks.
4. Other Income: Most recent copy of Social Security check or copy of award letter, proof of unemployment
compensation, workers’ compensation, pension, child support or alimony.
5. Self-Employment: Most recent federal tax return (Schedule C Form) or last three months of business
records.
6. Rental Income: If you get paid by someone who rents a room or apartment from you, a copy of the lease
agreement or statement from your tenant showing the amount of rent paid.
7. Noncitizen Status: For all non-US citizens applying for SNAP benefits, alien registration card or other
immigration document.
8. Child Support Payments: If you make child support payments to someone not living with you, show
proof of the legal obligation to make the payment, such as a court order, tax returns showing legally
obligated support payments, verification of withholding from unemployment compensation, and the
amount paid.
1. Housing Costs: rent receipt or mortgage statement, real estate taxes or homeowners’ insuranc
e bill.
2. Utilities: home heating oil, gas, electricity, telephone (including cell phones), or other utility expenses
such as garbage disposal, wood or coal
3. Child Care or Adult Dependent Care Expenses in-home or out-of-home care
4. Medical Expenses: If you or anyone in your household is age 60 or older or has a certified disability, out-
of-pocket medical expenses must be verified with receipts for co-payments or premiums on health
insurance, or receipts for dentures, eyeglasses, hearing aids, hearing aid batteries, prescription
medications, doctor-prescribed pain relievers or over-the-counter drugs, and transportation to get to and
from medical services.
Note: Certain households, such as those with disqualified members, will be asked to provide information
and verification of bank accounts and other assets.
After your interview, you will get a list of things you will need to show us. Pay stubs, utility bills and
other proof must not be more than four weeks old from the day that you turn in your application.
Things you may provide, if they apply to you, to receive higher SNAP benefits. SNAP rules allow
you to deduct certain expenses from your countable income.
ii
SNAPA-1 (Rev.10/2014)
25-170-1014-05
Massachusetts Department of Transitional Assistance
SNAP Benefits Application
1. Information About You (Answer all boxes.) If you are a noncitizen who chooses NOT to apply for SNAP
benefits, you do not need to tell us your Social Security number or immigration status.
Last Name First Name Middle Initial Social Security Number
- -
Is this name your (check one)  Name at Birth Maiden Name Married Name 
Prior Marriage Name Alias
Date of Birth Gender
M F
Are you pregnant?
yes no
Marital Status (ch
eck one) 
Married Never Married Divorced 
Separated Widowed
What is your preferred language?
Your ethnicity/race: This information is collected to make sure everyone is treated 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

Native Hawaiian or Other Pacific Islander White
Do you have a special situation? (Check all boxes that apply to you.)
Physical/Mental Impairment Hearing Impaired Visually Impaired
Interpreter Required Sign Language Required Other____________________
2. Information About Where You Live and How to Contact You (Answer all boxes.)
Your
current
address
Number and Street Apt # City, State, ZIP
Are you homeless? yes no Is your current address temporary? yes no
Is your current address your mailing address?
yes no
If a temporary address, list your permanent address.
If you have a different mailing address, please list.
Type of housing you live in
Private Housing Public Housing Commercial Boarding House
Transitional Housing Residential Facility Employer-provided Housing
Teen Living Program Migrant Campsite Shelter
Temporary Housing (eg. car, tent) Student Housing (e.g. dormitory)
Source: (please check one)
CEO Project Bread DMH
DMR BMC Food Pantry
MRC Other _______________
SNAPA-1(Rev.10/2014)
25
-170-1014-05
1
FSA-1
2. Information About Where You Live and How to Contact You (Continued)
If you have an email address, please list: __________________________________________________
Your daytime telephone number(s)
( ________ ) _________-_______________ ( ________ ) _________-_______________
A good time of day to reach you by telephone: Time: ________________
Circle all that apply:
Monday Tuesday Wednesday Thursday Friday
3. Person Helping with Your Application
Last Name First Name Middle Initial Telephone Number
Number and Street City/Town State ZIP
4. Authorized Representative
Do you want to give this person permission to apply or get SNAP benefits for you? yes no
5. Waiver of the Face-to-Face Interview
If you are unable to come to the DTA office for an interview, please check all reasons that apply.

Elderly/Disabled Transportation Problems Work during DTA office hours

Child Care/Care of Disabled Household Member Other __________________
IMPORTANT: Be sure to list your telephone number(s) on page 1. We need to be able to call you if we
have questions about your application or have to interview you over the phone.
6. Questions Regarding Citizenship Status
a. Are you and all household members U.S. citizens by birth or naturalization? yes no
If Yes, go to Question 7. If No, go to Part b, below.
b. Under SNAP rules (106 CMR 362.220), a noncitizen who is unable or unwilling to provide immigration
status information and/or Social Security number due to immigration status does not need to do so. This
noncitizen will be ineligible for SNAP benefits. However, the remaining members of the household may
apply for benefits.
1. List any household member(s) who chooses NOT to apply for SNAP benefits:
2. Check here if all members choose to apply:
2
SNAPA-1 (Rev.10/2014)
25-170-1014-05
FSA-1
7. Information About People You Live With - Please list everyone you live with. Do not include yourself.
(Attach a separate sheet if necessary.) Noncitizens living with you who choose not to apply for SNAP benefits do not
need to tell us their Social Security number or immigration status.
Last Name First Name Middle Initial
Date of Birth Gender
M F
Relationship to you
Do you purchase and prepare
food together?
yes no
Is this person applying for SNAP
benefits? yes no
Social Security Number
- -
Marital Status
Pregnant?
yes no
Last Name First Name Middle Initial
Date of Birth Gender
M F
Relationship to you
Do you purchase and prepare
food together?
yes no
Is this person applying for SNAP
benefits? yes no
Social Security Number
- -
Marital Status
Pregnant?
yes no
Last Name First Name Middle Initial
Date of Birth Gender
M F
Relationship to you
Do you purchase and prepare
food together?
yes no
Is this person applying for SNAP
benefits? yes no
Social Security Number
- -
Marital Status
Pregnant?
yes no
8. Is there a child(ren) under age 18 living with you who is not your child, and who is not under your supervision
and control?
yes no
If yes, who? ______________________________________________________________________________
9. Is anyone living with you a roomer or boarder (person who pays for a room or room and meals)?
yes no
If yes, what is this person’s name? ____________________________________________________________
10. Are foster care payments being made to your household for anyone living with you?
yes no
If yes, for whom are the payments being made? _________________________________________________
11. Are you or is anyone living with you a resident of a state other than Massachusetts or country other than the U.S.
or are you or is anyone living with you intending to leave Massachusetts?
yes no
If yes, who is not a resident or is intending to leave? ______________________________________________
12. Are you or is anyone living with you NOT a U.S. citizen?
yes no
13. Do you or anyone living with you who is 18 or older and a United States citizen and Massachusetts resident want to
register to vote
yes no
If yes, who would like to register? _____________________________________________________________
14. Are you or is anyone living with you physically or mentally disabled temporarily or long-term?
yes no
If yes, who is disabled? ____________________________________________________________________
3
SNAPA-1 (Rev.10/2014)
25-170-1014-05
FSA-1
15. Earnings
Are you or is anyone living with you presently working, or were you or anyone else living with you working in the
last 60 days?
yes no
If yes, complete the following section.
(Attach a separate sheet, if necessary.)
IMPORTANT: Be sure to complete this section if you or anyone else living with you is self-employed.
Last Name First Name Employer Name, Address & Telephone Number
Job Title Start Date End Date Hourly Wage
$ ________
Weekly
Hours
Weekly
Tips
$ _______
How Often
Paid?
Permanent
Job?
yes no
If job ended, last day of work ______/_____/_______
Record most recent wage information here:
Date
From To
Gross Amount Hours
$
$
$
Name Type of Income Amount How often
received?
Date Income
Started
17. Do you or does anyone living with you have a court order (legal obligation) to pay child support to a child not living
with you?
yes noHow often paid? Monthly Weekly Amount $ ___________________
18. Do you or does anyone living with you have child care or adult dependent care expenses?
yes no
How often paid?
Monthly Weekly Amount $ ___________________
19. Do you or does anyone living with you who is 60 years old or older or who is disabled have health insurance
expenses?
yes no How often paid? Monthly Weekly Amount $ ___________________
20. Do you or does anyone living with you who is 60 years old or older or who is disabled have out-of-pocket medical
expenses?
yes no If yes, complete the following section.
Name Type How often
paid?
Amount Date you started
paying
16. Other Income
Are you or is anyone living
with you eligible to receive or receiving any other type of income such as
Unemployment Compensation, Child Support, Social Security, SSI, Workers’ Compensation, Veterans’ Benefits,
Pensions or Rental Income?
yes no
If yes, complete the following section.
(Attach a separate sheet, if necessary.)
4
SNAPA-1 (Rev.10/2014)
25-170-1014-05
FSA-1
21. Shelter Expenses
What type of shelter expenses do you have?
Rent/Mortgage
yes no Rent/Mortgage amount per month $ ____________
Property Taxes
yes no
Other
yes no
22. Utility Expenses
What type of utility expenses do you pay for separate from your rent?
1. I pay to heat my home (oil, gas, electricity or propane, etc.) or share heating costs with others.
yes no
2. I have an air conditioner that I use in the summer, and I pay for electricity or share the cost with others.
yes no
3. I have an air conditioner that I use in the summer, and I pay a fee to use it.
yes no
4. I pay for electricity or gas or share this cost with others.
yes no
5. I pay for phone service, including cell phone service (not a pre-paid phone).
yes no
NOTICE OF RIGHTS, RESPONSIBILITIES AND PENALTIES (PLEASE READ CAREFULLY)
I certify under penalty of perjury that I have read, or have had read to me, the information in this application and
my answers to the questions in this application and such answers are true and complete to the best of my
knowledge. I also certify under penalty of perjury that my answers on any supplement I may complete in the future
will be true and complete to the best of my knowledge. I understand that giving false or misleading statements or
misrepresenting, hiding or withholding facts, either orally or in writing, to establish eligibility for SNAP is fraud, an
Intentional Program Violation (IPV), and is punishable by civil and criminal penalties.
I understand that the information I provide with my application w
ill be subject to verification by Federal,
State and local officials, to determine if such information is true; if any information is false, SNAP benefits
may be denied, and I may be subject to criminal prosecution for knowingly providing false information.
I understand that the Department of Transitional Assistance (DTA) administers SNAP, and that DTA ha
s 30 days
from the date of application to process the application. I understand that I must report to DTA any changes in my
household income, assets, address, living arrangement, family size, employment or any other 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 unless I am allowed by DTA to report changes under the SNAP
Annual Reporting rules or Transitional Benefits Alternative (TBA) rules.
I understand that I have a right to speak to a supervisor, if I am determined ineligible for expedited SNAP benefits
and I disagree, or if I am determined eligible for expedited service but do not receive my SNAP benefits by the
seventh calendar day after the date I applied for SNAP.
I understand that if I choose to report child or other dependent care expenses, rent/mortgage, other shelter or
utility expenses, I may receive a higher SNAP benefit. Also I understand that if I pay child support to a non-
household member I can report and provide proof to DTA for this expense. If I do not report or verify the above-
listed expenses(s), it could mean that I will receive less SNAP benefits each month and will be seen as my
statement that the household does not want to receive a deduction for the unreported or unverified expense(s).
SNAPA-1 (Rev.10/2014)
25-170-1014-05
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FSA-1
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 may be barred from SNAP for one year after the first violation, two years after the second violation and
permanently after the third violation. The person may be prohibited from receiving SNAP for 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 prohibited from receiving SNAP for an additional
18 months if court ordered. 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 entitled to receive.
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) that is confirmed in an
Administrative Disqualification Hearing (ADH), will be barred from SNAP for the same period the individual
is barred from cash assistance.
Individuals who make a fraudulent statement or representation about their identity or place of residence to
receive multiple SNAP benefits simultaneously will be barred from SNAP for ten years.
Individuals who trade (buy or sell) SNAP benefits for a controlled substance/illegal drug(s), will be barred
from SNAP for a period of two years for the first finding, and permanently for the second finding.
Individuals who trade (buy or sell) SNAP benefits for firearms, ammunition or explosives, will be barred
from SNAP permanently.
Individuals who trade (buy or sell) SNAP benefits having a value of $500 or more, will be barred from
SNAP permanently.
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 a condition of probation or parole, are ineligible to participate in SNAP.
Individuals who fail to comply without good cause with SNAP Work Requirements will b
e disqualified from
SNAP for a period of three months for the first
finding, six months for the second finding and twelve
months for the third finding. If the individual found to have failed to comply for a third time is the head of
the SNAP household, the entire household shall be ineligible to participate in SNAP for a period of six
months.
Paying for food purchased on credit is not allowed and can result in disqualification from SNAP.
Individuals may not purchase 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.
Nondiscrimination Statement
The U.S. Department of Agriculture prohibits discrimination against its customers, employees and applicants for
employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and,
where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an
individual’s income is derived from any public assistance program, or protected genetic information in employment
or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all
programs and/or employment activities.)
SNAPA-1 (Rev.10/2014)
25-170-1014-05
7
FSA-1
Nondiscrimination Statement
The U.S. Department of Agriculture prohibits discrimination against its customers, employees and applicants for
employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and,
where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an
individual’s income is derived from any public assistance program, or protected genetic information in employment
or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all
programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or
call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in
the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director,
Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442
or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339; or (800) 845-6136 (Spanish).
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should
either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State
Information Hotline Numbers (click the link for a list of hotline numbers by State), found online at
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
USDA is an equal opportunity provider and employer.
Massachusetts law also prohibits discrimination, including discrimination based on ancestry. To file a complaint in
Massachusetts contact:
Massachusetts Commission Against Discrimination, One Ashburton Place, Sixth Floor, Room 601, Boston, MA
02108; Phone: (617) 994-6000; TTY: (617) 994-6196.
Applicant Signature:____________________________________________ Date__________________________
APPLICANT’S SIGNATURE: By signing this application, I hereby certify under penalty of
perjury that I have read (or have had read to me) and I understand and agree to the “Rights and
Responsibilities,” and the answers in this application and any additional documents I provide to the
Department in the future are accurate and complete to the best of my knowledge. I have read the SNAP
Penalty Warning in my primary language, have had it read to me or have had it interpreted for me. I also
certify that all members of my SNAP household requesting SNAP benefits are either U.S. citizens or
noncitizens in satisfactory immigration status.
SNAPA-1 (Rev.10/2014
)
25-170-1014-05
8
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Commonwealth of Massachusetts SNAP Benefits Application

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Completed 23 May 2020

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