Affidavit to Verify
When you send us this form, please include a copy of the letter that we sent you asking for proof of your
income. The letter is called a “Request for Information.”
Tell us about yourself. Please print.
First name Middle initial Last name
Date of birth (MM/DD/YYYY)
Social Security number
Read and sign this form.
I do not receive any income at this time.
By signing below, I swear under the pains and penalties of perjury that everything on this form is true and complete to the
best of my knowledge.
I know that if I lie on this form, my health coverage might end and I might have to repay Massachusetts for any tax credits
or health benets I got.
Applicant, member, or authorized representative signature
Return this signed form in one of these 3 ways.
1. FAX: (857) 323-8300
2. Mail: Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
3. In person:
MassHealth Enrollment Centers
45 Spruce Street 21 Spring Street, Suite 4
Chelsea, MA 02150 Taunton, MA 02780
100 Hancock Street, 6th Floor 367 East Street
Quincy, MA 02171 Tewksbury, MA 01876
88 Industry Avenue, Suite D The Schrafft Center
Springeld, MA 01104 529 Main Street, Floor M
Charlestown, MA 02129
Health Connector Walk-in Centers
133 Portland Street
Boston, MA 02114
63 Main Street
Brockton, MA 02301
146 Main Street
Worcester, MA 01608
Call the Health Connector at (877) MA ENROLL, (877) 623-6765 or TTY: (877) 623-7773.
Or call MassHealth at (800) 841-2900 or TTY: (800) 497-4648.