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Home My Public Portal AboutSNAP Application Package Massachusetts Department of Transitional Assistance 61$3%(1(),76)25<28$1'<285)$0,/< $33/<72'$<,7¶6($6,(57+$1<287+,1. HOW TO APPLY 7RDSSO\IRU61$3EHQHILWVSOHDVHILOORXWWKLVDSSOLFDWLRQDQGPDLOLWWR'7$'RFXPHQW3URFHVVLQJ&HQWHU 32%R[7DXQWRQ0$RUID[WR,I\RXZDQWPRUHLQIRUPDWLRQSOHDVHFDOO RUYLVLWRXUZHEVLWHDWZZZPDVVJRYGWD<RXFDQDOVRDSSO\IRU61$3EHQHILWVRQOLQHE\ JRLQJWRZZZPDVVJRYYJVHOIVHUYLFH ,03257$17:HZLOODFFHSW\RXUDSSOLFDWLRQLILWFRQWDLQV\RXUQDPHDQGDGGUHVVif you have one RQSDJHDQG\RXUVLJQDWXUHRQSDJH7KLVPLQLPDOLQIRUPDWLRQZLOOHVWDEOLVK\RXUDSSOLFDWLRQ ILOLQJGDWH+RZHYHUWKHUHPDLQLQJLQIRUPDWLRQRQWKHIRUPPXVWEHFRPSOHWHGDQGZHPXVWLQWHUYLHZ\RX WRGHWHUPLQH\RXUHOLJLELOLW\%HQHILWVDUHSURYLGHGIURPWKHGDWHRIDSSOLFDWLRQ 3OHDVHWU\WRDQVZHUDOOWKHTXHVWLRQVRQWKHDSSOLFDWLRQ7KHPRUHLQIRUPDWLRQZHKDYHWKHPRUHTXLFNO\ZH ZLOOEHDEOHWRDFWRQ\RXUDSSOLFDWLRQ,I\RXDUHQ¶WVXUHZKDWDTXHVWLRQPHDQVRUKRZWRDQVZHULWOHDYHLW EODQNDQGZHZLOOWDONDERXWLWGXULQJ\RXULQWHUYLHZ$IWHUZHUHFHLYH\RXUDSSOLFDWLRQZHZLOOFRQWDFW\RXIRU DQLQWHUYLHZDQGDVN\RXPRUHTXHVWLRQV7KLVLQWHUYLHZZLOOWDNHSODFHHLWKHULQDQRIILFHRURYHUWKH WHOHSKRQH,I\RXQHHGDQLQWHUSUHWHUWRKHOS\RXFRPSOHWHWKLVIRUPRUIRUWKHLQWHUYLHZWHOOXVDQGZHZLOO DUUDQJHIRURQH%HORZZHOLVWWKHW\SHVRIWKLQJV\RXZLOOQHHGWRSURYLGHIRU\RXUDSSOLFDWLRQ3OHDVHORRNDW WKHOLVWDQGJDWKHUWKHSURRIV\RXZLOOQHHG YOU MAY GET SNAP BENEFITS WITHIN SEVEN DAYS IF ONE OF THE FOLLOWING IS TRUE: x'RHV\RXULQFRPHDQGPRQH\LQWKHEDQNDGGXSWROHVVWKDQ\RXUPRQWKO\KRXVLQJH[SHQVHV" \HVQR x,V\RXUPRQWKO\LQFRPHOHVVWKDQDQG\RXUPRQH\LQWKHEDQNRUOHVV"\HVQR x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hings you must provide, if they apply to you, to receive SNAP benefits 1.Proof of Identity: Driver’s license, birth 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’ insurance 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 (check 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? ____________________________________________________________________ 3SNAPA-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 will 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 has 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). 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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 be 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