Ssi Food Stamp Benefits Reapplication Form Page 2
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SSI Food Stamp Benefits Reapplication Form
Date received: ___/___/______
¡Importante! Si usted no puede leer esta solicitud, copias en español estaràn disponibles en su oficina
local de Asistencia Transicional.
Important:
Complete this form only if you want to continue to receive food stamp benefits.
Name
Social Security Number
Street Address
City/Town
State
ZIP
Mailing Address
City/Town
State
ZIP
(________)___________________________________
(________)_______________________________
Home Telephone Number
Other Telephone Number
What language do you understand and speak fluently?
How long have you lived in Massachusetts?
years
1) Household Members
Do you live and eat alone?
yes
no
If no, do not complete this application; contact your SSI Regional Office to continue your food stamp
benefits.
2) Citizenship
Are you a U.S. citizen?
yes
no
If not, what is your citizenship status?
If a noncitizen, submit a copy of the front and back of your Resident Alien Card.
3) Income from Work
Do you receive any money for working?
yes
no (includes self-employment)
If yes, do not complete this application; contact your SSI Regional Office to continue your food stamp
benefits.
4) Income from Roomers and Boarders
Do you receive income from the rental of an apartment or from the rental of a room or for providing
meals to someone?
yes
no
If yes, do not complete this application; contact your SSI Regional Office to continue your food stamp
benefits.
5) Other Income
Do you receive income from any other sources?
yes
no (i.e., Alimony, Pension, State or
Federal Veterans’ Benefits, Unemployment or Workers’ Compensation)
If yes, do not complete this application; contact your SSI Regional Office to continue your food stamp
benefits.
6) Medical Expenses
Do you have any medical expenses over $35 a month that are not paid by Medicare, private health
insurance, or MassHealth?
yes
no
If yes, how much over $35?
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