offered by
Department of Transitional Assistance
related to
SNAP benefits (formerly food stamps)

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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SNAP documents and forms

SNAP معاملة تقديم على فوائد برنامج المساعدات الغذائية التكميلية (PDF 284.21 KB)

SNAP Benefits Application (SNAPA-1)(Arabic)

SNAP معاملة تقديم على فوائد برنامج المساعدات الغذائية التكميلية (DOCX 223.23 KB)

SNAP Benefits Application (SNAPA-1)(Arabic)

SNAP 福利申请表 (PDF 408.37 KB)

SNAP Benefits Application (SNAPA-1)(Chinese)

SNAP 福利申请表 (DOCX 112.41 KB)

SNAP Benefits Application (SNAPA-1)(Chinese)

SNAP benefits application (PDF 690.76 KB)

(SNAPA-1)(fillable)

SNAP benefits application (DOCX 230.72 KB)

(SNAPA-1)

Demande d’allocation SNAP (PDF 245.51 KB)

SNAP Benefits Application (SNAPA-1)(French)

Demande d’allocation SNAP (DOCX 124.97 KB)

SNAP Benefits Application (SNAPA-1)(French)

Aplikasyon pou Avantaj SNAP (PDF 270.51 KB)

SNAP Benefits Application (SNAPA-1)(Haitian Creole)

Aplikasyon pou Avantaj SNAP (DOCX 126.38 KB)

SNAP Benefits Application (SNAPA-1)(Haitian Creole)

Richiesta di prestazioni SNAP (PDF 231.12 KB)

SNAP Benefits Application (SNAPA-1)(Italian)

Richiesta di prestazioni SNAP (DOCX 159.11 KB)

SNAP Benefits Application (SNAPA-1)(Italian)

Khmer SNAP Benefits Application (PDF 324.55 KB)

SNAP Benefits Application (SNAPA-1)(Khmer)

Khmer SNAP Benefits Application (DOCX 146.61 KB)

SNAP Benefits Application (SNAPA-1)(Khmer)

SNAP 혜택 신청서 (PDF 404.03 KB)

SNAP Benefits Application (SNAPA-1)(Korean)

SNAP 혜택 신청서 (DOCX 127.34 KB)

SNAP Benefits Application (SNAPA-1)(Korean)

Wniosek o świadczenia SNAP (PDF 372.72 KB)

SNAP Benefits Application (SNAPA-1)(Polish)

Wniosek o świadczenia SNAP (DOCX 154.35 KB)

SNAP Benefits Application (SNAPA-1)(Polish)

Pedido de Benefícios do SNAP (PDF 622.51 KB)

SNAP Benefits Application (SNAPA-1)(Portuguese, fillable)

Pedido de Benefícios do SNAP (DOCX 229.85 KB)

SNAP Benefits Application (SNAPA-1)(Portuguese)

Заявление на получение пособия по программе SNAP (PDF 375.38 KB)

SNAP Benefits application (SNAPA-1)(Russian)

Заявление на получение пособия по программе SNAP (DOCX 159.88 KB)

SNAP Benefits application (SNAPA-1)(Russian)

Solicitud de beneficios de SNAP (PDF 709.58 KB)

SNAP Benefits Application (SNAPA-1)(Spanish, fillable)

Solicitud de beneficios de SNAP (DOCX 228.75 KB)

SNAP Benefits Application (SNAPA-1)(Spanish)

Đơn Xin Trợ Cấp SNAP (PDF 362.05 KB)

SNAP Benefits Application (SNAPA-1)(Vietnamese)

Đơn Xin Trợ Cấp SNAP (DOCX 172.22 KB)

SNAP Benefits Application (SNAPA-1)(Vietnamese)

نموذج طلب SNAP لكبار السنّ (PDF 421.94 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Arabic)

نموذج طلب SNAP لكبار السنّ (DOCX 141.53 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Arabic)

补充营养援助计划（SNAP）年长者申请表 (PDF 589.92 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Chinese)

补充营养援助计划（SNAP）年长者申请表 (DOCX 166.71 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Chinese)

SNAP Application for Seniors (PDF 385.08 KB)

(SNAP‐App‐Seniors)(fillable)

SNAP Application for Seniors (DOCX 98.54 KB)

(SNAP‐App‐Seniors)

Demande d'allocation SNAP par une personne âgée (PDF 560.55 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(French)

Demande d'allocation SNAP par une personne âgée (DOCX 96.58 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(French)

Aplikasyon SNAP pou granmoun (PDF 571.57 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Haitian Creole)

Aplikasyon SNAP pou granmoun (DOCX 91.42 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Haitian Creole)

Richiesta di sussidi alimentari SNAP per anziani (PDF 552.02 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Italian)

Richiesta di sussidi alimentari SNAP per anziani (DOCX 104.51 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Italian)

ពាក្យសុំ SNAP សំរាប់ព្រឹទ្ធាវ័យ (PDF 431.77 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Khmer)

ពាក្យសុំ SNAP សំរាប់ព្រឹទ្ធាវ័យ (DOCX 125.91 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Khmer)

노인 SNAP 신청서 (PDF 529.63 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Korean)

노인 SNAP 신청서 (DOCX 107.19 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Korean)

Wniosek o SNAP dla osób starszych (PDF 583.7 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Polish)

Wniosek o SNAP dla osób starszych (DOCX 94.21 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Polish)

Formulário de inscrição de idosos no SNAP (PDF 456.01 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Portuguese, fillable)

Formulário de inscrição de idosos no SNAP (DOCX 88.39 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Portuguese)

Форма заявления на участие в программе SNAP для пожилых людей (PDF 599.76 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Russian)

Форма заявления на участие в программе SNAP для пожилых людей (DOCX 100.08 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Russian)

SNAP Solicitud para personas mayores (PDF 378.03 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Spanish, fillable)

SNAP Solicitud para personas mayores (DOCX 86.35 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Spanish)

Đơn Xin SNAP dành cho Người Cao Niên (PDF 608.43 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Vietnamese)

Đơn Xin SNAP dành cho Người Cao Niên (DOCX 91.01 KB)

SNAP Application for Seniors (SNAP‐App‐Seniors)(Vietnamese)

Community College Verification Form (PDF 17.55 KB)

(CCE-1)

Community College Verification Form (DOCX 45.06 KB)

(CCE-1)

SNAP Work Requirement Medical Report (PDF 397.69 KB)

(FSPWR-WP-MED)

SNAP Work Requirement Medical Report (DOCX 46.56 KB)

(FSPWR-WP-MED)

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

English version (PDF)

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

English version (MS Word)

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

Spanish version (PDF)

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

English version (PDF)

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

English version (MS Word)

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

Spanish version (PDF)

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

Spanish version (MS Word)

SNAP Medical Expenses Brochure (SNAP-MEB) (PDF 198.14 KB)

English version (PDF)

SNAP Medical Expenses Brochure (SNAP-MEB) (DOCX 154.53 KB)

English version (MS Word)

SNAP Medical Expenses Brochure (SNAP-MEB) (PDF 206.24 KB)

Portuguese version (PDF)

SNAP Medical Expenses Brochure (SNAP-MEB) (DOCX 155.47 KB)

Portuguese version (MS Word)

SNAP Medical Expenses Brochure (SNAP-MEB) (PDF 194.18 KB)

Spanish version (PDF)

SNAP Medical Expenses Brochure (SNAP-MEB) (DOCX 148.91 KB)

Spanish version (MS Word)

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

(PDF)

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

(MS Word)

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (PDF 244.93 KB)

(English version)(PDF)

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (DOCX 40.15 KB)

English version (MS Word)

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (PDF 198.87 KB)

Spanish version (PDF)

Request for Replacement SNAP Benefits Due to Household Disaster or Misfortune for Massachusetts Residents (SNAP-9B) (DOCX 51.98 KB)

Spanish version (MS Word)

Permission to Share Information Form (PDF 192.39 KB)

(PSI)(fillable)

Permission to Share Information Form (PDF 204.4 KB)

Permission to Share Information Form (PSI)(Spanish, fillable)

Economic Assistance (cash benefits) documents and forms

Application for Funeral and Final Disposition Benefit (PDF 216.86 KB)

F&FD-1

Application for Funeral and Final Disposition Benefit (PDF 409.8 KB)

Spanish version (Fillable PDF)

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

English version (PDF)

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

English version (MS Word)

Authorization for reimbursement of interim assistance Initial claim or posteligibility case (PDF 215.94 KB)

Spanish version (PDF)

Authorization for reimbursement of interim assistance Initial claim or posteligibility case (DOCX 19.13 KB)

Spanish version (MS Word)

Direct Deposit Form (PDF 122.71 KB)

(PDF)

Direct Deposit Form (DOCX 91.23 KB)

(MS Word)

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

English version (PDF)

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

English version (MS Word)

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

Spanish version (PDF)

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

Spanish version (MS Word)

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

(PDF)

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

(MS Word)

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

(PDF)

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

(MS Word)

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

English version (PDF)

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

English version (MS Word)

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

Spanish version (PDF)

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

Spanish version (MS Word)

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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