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Department of Transitional Assistance documents and forms

Below are commonly requested documents and forms for programs offered by the Department of Transitional Assistance (DTA).

Below is a list of common DTA forms and documents that you may need. While most are available online, if you do not find your document here or on DTA Connect, you can request another one by calling the DTA Assistance Line at (877) 382-2363.

SNAP Recertifications and Interim Reports can now be filled out online. Login to DTAConnect.com to fill out your SNAP Recertification form or your Interim Report today.

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Table of Contents

SNAP documents and forms

Arabic SNAP Benefits Application (SNAPA-1) (PDF 373.43 KB)

PDF version

Chinese SNAP Benefits Application (SNAPA-1) (PDF 467.29 KB)

PDF version

English SNAP benefits application (SNAPA-1) (PDF 651.79 KB)

PDF version (fillable)

French SNAP Benefits Application (SNAPA-1) (PDF 493.61 KB)

PDF version

Haitian Creole SNAP Benefits Application (SNAPA-1) (PDF 456.45 KB)

PDF version

Italian SNAP Benefits Application (SNAPA-1) (PDF 491.45 KB)

PDF version

Khmer SNAP Benefits Application (SNAPA-1) (PDF 537.11 KB)

PDF version

Korean SNAP Benefits Application (SNAPA-1) (PDF 400.02 KB)

PDF version

Polish SNAP Benefits Application (SNAPA-1) (PDF 439.7 KB)

PDF version

Portuguese SNAP Benefits Application (SNAPA-1) (PDF 649.79 KB)

PDF version (fillable)

Russian SNAP Benefits application (SNAPA-1) (PDF 450.38 KB)

PDF version

Spanish SNAP Benefits Application (SNAPA-1) (PDF 689.23 KB)

PDF version (fillable)

Vietnamese SNAP Benefits Application (SNAPA-1) (PDF 430.41 KB)

PDF version

Arabic SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 309.08 KB)

PDF version

Chinese SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 407.5 KB)

PDF version

English SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 535.99 KB)

PDF version (fillable)

French SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 422.02 KB)

PDF version

Haitian Creole SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 378.47 KB)

PDF version

Italian SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 427.9 KB)

PDF version

Khmer SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 446.08 KB)

PDF version

Korean SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 319.33 KB)

PDF version

Polish SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 382.2 KB)

PDF version

Portuguese SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 536.18 KB)

PDF version (fillable)

Russian SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 385.76 KB)

PDF version

Spanish SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 553.82 KB)

PDF version (fillable)

Vietnamese SNAP Application for Seniors (SNAP‐App‐Seniors) (PDF 372.93 KB)

PDF version

Community College Verification Form (CCE-1) (PDF 17.55 KB)

PDF version

Community College Verification Form (CCE-1) (DOCX 45.06 KB)

MS Word version

SNAP Work Requirement Medical Report (FSPWR-WP-MED) (PDF 397.69 KB)

PDF version

SNAP Work Requirement Medical Report (FSPWR-WP-MED) (DOCX 46.56 KB)

MS Word version

Request to Choose Someone to Be My Authorized Representative (Image-10) (PDF 324.93 KB)

PDF version

Request to Choose Someone to Be My Authorized Representative (Image-10) (DOCX 100.52 KB)

MS Word version

Spanish Request to Choose Someone to Be My Authorized Representative (Image-10) (PDF 292.85 KB)

PDF version

Request for Agency Employee(s) to be my SNAP Authorized Representative (Image-10a) (PDF 212.62 KB)

PDF version

Request for Agency Employee(s) to be my SNAP Authorized Representative (Image-10a) (DOCX 90.91 KB)

MS Word version

Spanish Request for Agency Employee(s) to be my SNAP Authorized Representative (Image-10a) (PDF 166.39 KB)

PDF version

Spanish Request for Agency Employee(s) to be my SNAP Authorized Representative (Image-10a) (DOCX 92.48 KB)

MS Word version

Other Agency Certification of Shelter and Utility Costs (FS-ACSE) (PDF 250.88 KB)

PDF version

Other Agency Certification of Shelter and Utility Costs (FS-ACSE) (DOCX 51.58 KB)

MS Word version

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (PDF 217.3 KB)

PDF version

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (DOCX 30.55 KB)

MS Word version

Spanish Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (PDF 251.54 KB)

PDF version

Spanish Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (DOCX 45.42 KB)

MS Word version

Permission to Share Information Form (PSI) (PDF 192.39 KB)

PDF version (fillable)

Spanish Permission to Share Information Form (PSI) (PDF 204.4 KB)

PDF version (fillable)

English Medical Expenses Flyer (PDF 225.16 KB)
English Medical Expenses Flyer (DOCX 233.82 KB)
Chinese Medical Expenses Flyer (PDF 281.69 KB)
Chinese Medical Expenses Flyer (DOCX 234.3 KB)
Haitian Creole Medical Expenses Flyer (PDF 223.55 KB)
Haitian Creole Medical Expenses Flyer (DOCX 182.89 KB)
Portuguese Medical Expenses Flyer (PDF 224.21 KB)
Portuguese Medical Expenses Flyer (DOCX 235.39 KB)
Spanish Medical Expenses Flyer (PDF 230.85 KB)
Spanish Medical Expenses Flyer (DOCX 176.22 KB)
Vietnamese Medical Expenses Flyer (PDF 306.11 KB)
Vietnamese Medical Expenses Flyer (DOCX 155.31 KB)

Economic Assistance (cash benefits) documents and forms

Application for Funeral and Final Disposition Benefit (F&FD-1) (PDF 291.06 KB)

PDF version (fillable)

Spanish Application for Funeral and Final Disposition Benefit (F&FD-1) (PDF 234.09 KB)

PDF version (fillable)

Authorization for reimbursement of interim assistance Initial claim or posteligibility case (AP-SSI-IAR) (PDF 261.61 KB)

PDF version

Authorization for reimbursement of interim assistance Initial claim or posteligibility case (AP-SSI-IAR) (DOCX 18.94 KB)

MS Word version

Spanish Authorization for reimbursement of interim assistance Initial claim or posteligibility case (AP-SSI-IAR) (PDF 215.94 KB)

PDF version

Spanish Authorization for reimbursement of interim assistance Initial claim or posteligibility case (AP-SSI-IAR) (DOCX 19.13 KB)

MS Word version

Direct Deposit Form (CA/DD) (PDF 122.71 KB)

PDF version

Direct Deposit Form (CA/DD) (DOCX 91.23 KB)

MS Word version

Emergency Aid to the Elderly, Disabled and Children Disability Supplement (EAEDC-DS) (PDF 180.96 KB)

PDF version

Emergency Aid to the Elderly, Disabled and Children Disability Supplement (EAEDC-DS) (DOCX 59.67 KB)

MS Word version

Spanish Emergency Aid to the Elderly, Disabled and Children Disability Supplement (EAEDC-DS) (PDF 191.43 KB)

PDF version

Spanish Emergency Aid to the Elderly, Disabled and Children Disability Supplement (EAEDC-DS) (DOCX 69.4 KB)

MS Word version

DTA EAEDC Medical Report (EAEDC-Med Rpt) (PDF 416.37 KB)

PDF version

DTA EAEDC Medical Report (EAEDC-Med Rpt) (DOCX 58.11 KB)

MS Word version

Good Cause Medical Statement (TAFDC‐GCMS) (PDF 173.51 KB)

PDF version

Good Cause Medical Statement (TAFDC‐GCMS) (DOCX 29.24 KB)

MS Word version

English Transitional Aid to Families with Dependent Children Disability Supplement form (TAFDC-DS) (PDF 253.2 KB)

PDF version

English Transitional Aid to Families with Dependent Children Disability Supplement form (TAFDC-DS) (DOCX 59.18 KB)

MS Word version

Spanish Transitional Aid to Families with Dependent Children Disability Supplement form (TAFDC-DS) (PDF 261.78 KB)

PDF version

Spanish Transitional Aid to Families with Dependent Children Disability Supplement form (TAFDC-DS) (DOCX 68.42 KB)

MS Word version

SNAP Disability Verification for Elderly Noncitizens (SNAP-DVEN) (DOCX 34.3 KB)

English and Spanish versions (MS Word)

Verification of Caring for the Disabled form (TAFDC-4) (PDF 147.45 KB)

(PDF)

Verification of Caring for the Disabled form (TAFDC-4) (DOCX 35.41 KB)

(MS Word)

Cross-Programs documents and forms

Client Feedback form (CF-1) (PDF 108.11 KB)

English version (fillable PDF)

Client Feedback form (CF-1) (DOCX 35.03 KB)

English version (MS Word)

Client Feedback form (CF-1) (PDF 135.16 KB)

Spanish version (fillable PDF)

Client Feedback form (CF-1) (DOCX 34.62 KB)

Spanish version (MS Word)

DTA mail/fax cover sheet (PDF 61.98 KB)

English version (PDF)

DTA mail/fax cover sheet (DOCX 102.4 KB)

English version (MS Word)

DTA mail/fax cover sheet (PDF 62.3 KB)

Spanish version (PDF)

DTA mail/fax cover sheet (DOCX 101.88 KB)

Spanish version (MS Word)

Educational Income and Expense form (EDUC-1) (PDF 450.53 KB)

English version (PDF)

Educational Income and Expense form (EDUC-1) (DOCX 35.24 KB)

English version (MS Word)

Voluntary Consent to Release Information (VARI-OI) (PDF 181.22 KB)

English version (PDF)

Voluntary Consent to Release Information (VARI-OI) (DOCX 20.21 KB)

English version (MS Word)

Voluntary Consent to Release Information (VARI-OI) (PDF 421.55 KB)

Spanish version (PDF)

Voluntary Consent to Release Information (VARI-OI) (DOCX 19.36 KB)

Spanish version (MS Word)

Contact

Phone

(877) 382-2363

Talk to a case manager between 8:15am-4:45pm, M-F. During off hours you can access case information via our automated system.

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