DTA forms

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DTA now has many forms online as part of its Online Guide.

Also see the Master list of DTA forms from prior years.

 

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DTA's EAEDC Medical Provider Statement

DTA
Here are the current procedures for DTA (As of December 2022):    EAEDC applicants and people doing an EAEDC reevaluation need to use the EAEDC Medical Provider Statement to verify disability if DTA can't get proof of disability from another source. The client must…

TAFDC Program Brochure (TAFDC-PB)

DTA
Click the "go to website" link to find the TAFDC brochure on DTA's website, in English and Spanish. 

Child Care Referral Form

DTA
The DTA's Child Care Referral form is attached.

Child Care Fact Sheet CCFS

DTA
Information from DTA about getting help paying for child care. English CCFS Spanish CCFS (S) Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Collateral Contact Form (Voluntary Authorization to Release Information/ VARI)

DTA
This form (VARI-OI) allows DTA worker to assist client with obtaining verifications from third parties such as employers, landlords, schools, etc.  Complete and send this form to DTA for verifications you do not have that are required for your SNAP benefits.  DTA also has a separate from…

SNAP Change Report SNAP-5

DTA
SNAP change report form. English SNAP-5 Spanish  SNAP-5 (S)  Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Food Stamp application --SSI households/individuals FSP/SSA-1

DTA
This Food Stamp/SNAP application form is one of the forms that may be used by Social Security District Offices for SSI recipients ineligible for Bay State CAP households, or SSI applicants who wish to apply for expedited or higher FS/SNAP benefits. SSA offices have an obligation to take SNAP…

Educational Income and Expense Form EDUC-1

DTA
DTA typically sends college students a special form, called the Educational Income and Expense Form (EDUC-1) to get information from the Financial Aid office about the student financial aid awards. Non-federal financial aid may affect SNAP or cash assistance. Here's the EDUC-1…

SNAP Community College Enrollment Verification Form CCE-1

DTA
Use this "Community College Enrollment" CCE-1 verification form to qualify student for SNAP benefits, or provide a letter from the college or other documents which provide the same information. English CCE-1 Click the "Go to Website" link below for the forms…

Appeals: Request for a DTA Appeal DOH-10

DTA
DTA's Request for an Appeal. English DOH-10 Spanish DOH-10 (S)   Please note that as of the summer of 2009, administration of the Emergency Assistance (EA) program was transferred from DTA to DHCD.  Therefore, you should not use the DTA forms to file an appeal of an…

DTA Request for Authorized Representative/Rep Payee Image-10

DTA
ALERT:  Do NOT use the "Authorized Rep/Rep Payee Form" if you are a legal representative or a social services agency and are  helping a client find out the status of their case, fix a  closed or denied SNAP or cash case problem. We recommend you…

DTA SNAP Program Informational Brochures

DTA
DTA SNAP Program Brochure - sent to  new SNAP applicants describing basic eligibility rules, rights, reporting responsibilities, household composition rules, student eligibilty and more.   Brochures in English, Spanish, Portuguese and Hatian Creole.

DTA Agreement to Repay form RER-1

DTA
Agreement to Repay DTA form English  RER-1 Spanish  RER-1 (S) Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Request for a Domestic Violence Waiver Form DVWR

DTA
Request for a waiver of TAFDC program requirement(s) due to domestic violence English DVWR Spanish DVWR Click the "Go to Website" link below for the forms included in DTA's Online Guide. Additional DTA resources on helping victims of domestic violence on public…

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune

DTA
Click the links to download the forms: English SNAP-9B Spanish SNAP-9B (S) See additional materials on SNAP Replacement Benefits due to household misfortune.

DTA Brochure: Your Right to Know

DTA
Your Right to Know brochure (YRTK) in English, Spanish, Portuguese and Haitian Creole. This brochure explains your rights and responsibilities if you receive Department benefits including Transitional Aid to Families with Dependent Children (TAFDC), Emergency Aid to the Elderly, Disabled and…

Landlord Verification Form LL-VR

DTA
The form does not ask the landlord to list all the household members or other questions irrelevant to receipt of benefits, but instead focuses on specific information needed for residence and shelter costs. It also advises the client of many alternative verifications instead of the form on the…

DTA Request for Employment Information DORL-1

DTA
English DORL-1 Click the "Go to Website" link below for the forms included in DTA's Online Guide.

TAFDC Good Cause Medical Statement form TAFDC-GCMS

DTA
Medical statement to be submitted to support a claim of good cause not to participate in work/ community service/ job search. English TAFDC-GCMS Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Permission to Access DTA Client Record: English, Spanish & Haitian Creole

MLRI
Below a SAMPLE consent statement - in English, Spanish and Haitian Creole - that helping agencies can use in order to speak with DTA about a specific case record or get copies of documents in the case record. This statement can be mailed or faxed to DTA, or…

DTA Shared Housing Verification Form VLA

DTA
Link to the DTA "Shared Housing Verification Form". Note, this is not a mandatory verification form. Households in doubled up living situations have a number of options to verify their residence (address) beyond this form. Also remember, shelter costs for SNAP can be self-declared…

Certificate of Immunization Status TAFDC-2

DTA
To be completed by a health care provider. English TAFDC-2 Click the "Go to Website" link below for the forms included in DTA's Online Guide.

DTA SNAP brochure on scope of medical expenses for elder or disabled households

DTA
This DTA brochure lists deductible medical expenses for SNAP applicants and recipients who are seniors or disabled.  Note that the standard medical deduction of $155 is used for SNAP households with with medical costs between $35.01 and $190 per month. If the SNAP…

Master Lists of DTA Forms

DTA
Master lists of DTA forms: 2015 2014 2011 2007 Also see the current list of online forms from the DTA Online Guide.

DTA Informational SNAP/Food Stamps Brochures in English & 8 Other Languages SNAP-BB

DTA
DTA brochure providing basic information about how to apply for Food Stamps/ SNAP benefits.  Each DTA brochure also has an insert with the current income standards.   The brochure (SNAP-BB) can be downloaded from DTA's online guide: English Arabic Chinese Haitian…

Case History for Family Cap Waiver Request FCWCH

DTA
This form must be completed by the DTA and submitted along with the Family Cap Exception/Waiver form whenever any recipient requests a waiver to the Family Cap rule. Case History for Family Cap Waiver Request (FCWCH) Click the "Go to Website" link below for the forms included in…

Cooperation with DOR notice DOR-CN

DTA
Cooperation with DOR notice. English DOR-CN Sent to Department of Revenue from DTA. Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Disability Supplement Form for EAEDC (EAEDC-DS)

DTA
In English and Spanish.

Two-Parent Exempt/ Nonexempt Status Notice TAFDC-5

DTA
This notice tells you whether you are exempt from the reduced need and payment standards and the 24-month time limit on Transitional Aid to Families with Dependent Children (TAFDC).  English TAFDC-5 Spanish TAFDC-5 (S) Click the "Go to Website" link below for the forms…

Do you need help because of a disability?

Office of Civil Rights
This OCR flier in English and 8 other languages discusses the ADA accommodation obligations of DTA for clients seeking DTA services.  English OCR-1 Spanish OCR-1 Chinese OCR-1 Laotian OCR-1 Khmer OCR-1 Haitian Creole OCR-1 Portuguese OCR-1 Russian…

Ops Memo 2014-49A: TAFDC and EAEDC – Self-Declarations and a Revised Form

DTA
Overview:  As part of the recent welfare reform legislation, it is now required that all self-declarations be signed under penalties of perjury. Attached is a form (Attachment A) that may be used for this purpose. Purpose of Memo:  This Operations Memo provides staff with a…

Funeral/Burial- Application for Payment of Expenses F & FD-1

DTA
Form to apply for funeral expenses from DTA. English F & FD-1 Spanish F & FD-1(S) Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Assignment of Support Rights, Cooperation with Child Support, or Good Cause Claim T-A 34/36

DTA
Assignment of Support Cooperation with Child Support Enforcement Division of the Massachusetts Department of Revenue (DOR) Good Cause Claim For use with TAFDC or MassHealth English T-A34/36 Spanish T-A34/36

Disability Supplement Form for TAFDC (TAFDC-DS)

DTA
In English and Spanish.

TAFDC Extension Request and Agreement

DTA
As part of Operations Memo 2013-9, DTA revised its TAFDC extension forms and procedures.  There is now a single form for both the extension request and the agreement.   See Ops Memo 2013-09 and 2012-37 for more information.

DTA Flier "Your Right to an Interpreter" in Multiple Languages

DTA
DTA has updated its brochure, "Your Right to Interpreter Services" in English and seven languages - pdfs of the brochure are available below.  This brochure can be used to help a client identify their language on the "I Speak" card (which includes additional languages). It also advised clients of…

DTA Brochure: Community Information - How May We Help You

DTA
DTA's Community Information Brochure with Where to Go for Help Contacts and SNAP/TAFDC Income Eligibility Charts Available in English, Cambodian-Khmer, Chinese, Haitian Creole, Portuguese, Russian, Spanish and Vietnamese. Also attached is an insert, 2013 SNAP eligibility chart…

EAEDC Program Brochure (EAEDC-PB)

DTA
EAEDC-PB (Rev. 12/2012)  (English) EAEDC-PB-S (Rev. 12/2012) (Spanish)

Time Limit- 24 Month Extension History, Recommendation for Extension Form

DTA
24 Month Extension History Form (24 EXHF) (Attachment C to Ops Memo 2012-37) (which becomes the Recommendation for Extension form).

Ops Memo 2012-19

DTA
The regulations at 106 CMR 705.350 provide for a relocation benefit to certain TAFDC families and EAEDC caretaker family households currently in shelters or teen living programs. The relocation benefit will help defray certain expenses that would prevent clients from securing permanent housing.The…

Interpreter Request Form IRF

DTA
Form used by DTA staff to request interpreter services from AT&T or Quest Language line. English IRF Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Ops Memo 2011-43: SNAP - Annual Reporting Process Phase Two: The Interim Report Process

DTA
Effective September 12, 2011 the Interim Report, phase two of the Annual Reporting (AR) process (see Operations memo 2011-31: SNAP – Annual Reporting Process), has been programmed into BEACON. Beginning 45 days before the end of the sixth month of the AR period, the Interim Reports will be…

Disability Determination Tracking Form DTF

DTA
To be completed by DTA. English DTF Click the "Go to Website" link below for the forms included in DTA's Online Guide.

Authorization for Reimbursement of Interim Assistance Initial Claim or Posteligibility Case AP-SSI-IAR

DTA
DTA requires this authorization form to be signed authorizing the Social Security Administration to reimburse the state for money and benefits the state gives you while you are waiting for a decision about SSI. English AP-SSI-IAR Spanish AP-SSI-IAR (S) Click the "Go to…

EA transfer from DTA to DHCD-- posters that explain the move (Spanish and English)

DHCD
Attached are posters for DTA offices about the transfer.

Noncitizen Resources Brochure in Spanish: NCRB-S

DTA

Verification Checklist -- English and Spanish (VC-1, VC-1S)

DTA
See attached.

ESP Provider Log Form and ESP Session Appointment letter

DTA
ESP Provider Session Log ESP Prov Log ESP Provider Session Appointment Letter  ESP Prov Appt Click the "Go to Website" link below for the forms included in DTA's Online Guide.

DES Functional Capacity Questionnaire

DES

DES Mental Impairment Questionairre

DES