Massachusetts Department Of Transitional Assistance Food Stamp Benefits Application Page 4
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83. People Helping with your Application
Do you want to give permission to someone else to apply or get food stamp benefits for you?
yes
no
Last Name
First Name
Middle Initial
Phone Number
Number
Street
City/Town
State
ZIP
You may be able to get expedited food stamp benefits within 7 days if you meet one of the
following rules and appear eligible for the program. Please answer the following questions.
4. Is the total of your gross monthly income before taxes and assets you can access easily
yes
no
less than your total combined monthly rent (or mortgage) and utilities?
5. Do you have monthly income before taxes of less than $150 and assets that you can
yes
no
access easily of $100 or less?
6. Are you a migrant or seasonal farmworker with assets of $100 or less?
yes
no
If you answered yes to question 4, 5, or 6, you should go to the office that serves your city or town to apply.
If you do not understand these questions, ask the worker to explain them. You have a right to a conference with
a supervisor, if we decide you cannot get food stamp benefits within 7 days and you disagree, or if you are
determined eligible for expedited service but you do not receive your food stamp benefits by the seventh calendar
day after the date you applied.
7. Domestic Violence
yes
no
Are you or is anyone in your household a victim of Domestic Violence currently or in the past?
8. Information about People you live with -
Please list everyone you live with and do not include yourself.
People living with you who do not want to apply for food stamp benefits do not
(Attach a separate sheet if necessary).
need to tell us their Social Security Number or immigration status.
Date of Birth
Relationship to you
Last Name
First Name
Middle Initial
Gender
/
/
M
F
Do you purchase & prepare
Social Security Number
Is this person applying for food stamp
benefits?
yes
no
food together?
yes
no
Preferred Language
Marital Status
Ethnicity
Pregnant?
yes
no
Date of Birth
Relationship to you
Last Name
First Name
Middle Initial
Gender
/
/
M
F
Do you purchase & prepare
Social Security Number
Is this person applying for food stamp
benefits?
yes
no
food together?
yes
no
Preferred Language
Marital Status
Ethnicity
Pregnant?
yes
no
Date of Birth
Last Name
First Name
Middle Initial
Gender
Relationship to you
/
/
M
F
Do you purchase & prepare
Social Security Number
Is this person applying for food stamp
benefits?
yes
no
food together?
yes
no
Preferred Language
Marital Status
Ethnicity
Pregnant?
yes
no
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