Appendix C: Important DTA Forms and Charts
DTA Forms
- Request to Choose Someone to be my Authorized Representative
- Request for an Appeal(Fair Hearing)
- DTA Medical Expense Self-Declaration Statement
MLRI Information and Sample Forms
- SNAP Mandatory Verifications Chart
- Sample Client Consent Allowing DTA to release Information to Helping Agency
- Sample Client Declaration of Shelter and Dependent Care Costs
- ABAWD fliers and information: MassLegalServices.org/ABAWD
- SNAP Medical Expense Deduction, including Know Your Rights flier (English and Spanish) and rent calculation worksheet toolkit: MassLegalServices.org/SNAP-medical
- College Students and SNAP, including Know Your Rights fliers: Masslegalservices.org/food4students
- Veterans Outreach Fliers: Masslegalservices.org/SNAP4veterans
- SNAP Know Your Rights Fliers:
- Household Misfortune/Replacement SNAP: MassLegalServices.org/SNAP-Misfortune
- SNAP and Strikers (English and Spanish): Masslegalservices.org/SNAPandstrikers
- SNAP and Dependent Care Expenses: https://www.masslegalservices.org/content/snap-and-dependent-care- child-care-deduction
- Adult Foster Care: Masslegalservices.org/content/adult-foster-care-and-snap
- Foster Care (children): https://www.masslegalservices.org/content/foster-care- families-and-snap
- Authorized Representatives vs. Helping Agencies:https://www.masslegalservices.org/content/helping-agency-vs-authorized-representative
- SNAP and the National School Lunch Program – Household Composition and Income Flier: Masslegalservices.org/NSLPvsSNAPincome
- Added Benefits of SNAP flier (in 5 languages): Masslegalservices.org/addedbenefitsofSNAP
- Public Charge Information: MassLegalServices.org/PublicCharge
- SNAP calculators: Masslegalservices.org/content/food-stamps-snap-calculators
MLRI's SNAP Math At a Glance Charts
- At-a-Glance Chart on SNAP for Working Households
- At-a-Glance Chart for Unemployment Comp Households
- At-a-Glance Chart for 1 and 2 Persons Elder/Disabled Households
- SNAP Benchmarks Chart for Claiming Medical Expenses
| Attachment | Size |
|---|---|
| 7 SNAP Verifications Chart- 2019 Guide final.pdf (186.13 KB) | 186.13 KB |
| Verifications- FAX Cover Sheet March 2013.pdf (34.16 KB) | 34.16 KB |
| appendix-c-sample-client-declaration-of-shelter-and-child-care-costs.pdf (389.45 KB) | 389.45 KB |