Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 13
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32STEP 2
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Person 3 (continued)
Tax filer date of birth
How is this person related to the tax filer?
Is the tax filer married, filing a joint return?
Yes
No
If yes, list name of spouse and date of birth.
Who else does the tax filer claim as dependents?
7. Is this person applying for health or dental coverage?
Yes
No
(Even if he or she has coverage, there might be a program with better coverage or lower costs. )
If yes, answer all the questions below. If no, answer Questions 14 and 15, then go to
Income Information
on page 8.
8. Is this person a U.S. citizen or U.S. national?
Yes
No
If yes, is this person a naturalized citizen (not born in the U.S.)?
Yes
No
Alien number
Naturalization or citizenship certificate number
9. If this person is a noncitizen, does he or she have an eligible immigration status?
Yes
No
See page 22, “Immigration Statuses and Document Types” for help. If no or no response, this person may get only one or more
of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the
Health Safety Net (HSN). Go to Question 10.
a. If yes, does this person have an immigration document?
Yes
No
It may help us to process this application faster if you include a copy of this person's immigration document with the
application. We will try to verify this person’s immigration status through an electronic data match. Please list all the
immigration statuses or conditions that have applied to him or her since this person entered the U.S. If you need more
space, attach another sheet of paper.
Status award date (mm/dd/yyyy)
(For battered persons, enter the date the petition was approved as
properly filed.)
Immigration status
Immigration document type
Choose one or more document status and types from the list on page 22.
Document ID number
Alien number
Passport or document expiration date (mm/dd/yyyy)
Country
b. Did this person use the same name on this application that he or she did to get this person's immigration status?
Yes
No
If no, what name did this person use? First, middle, last and suffix
c. Did this person arrive in the U.S. after August 22, 1996?
Yes
No
d. Is this person an honorably discharged veteran or active duty member of the U.S. military, or the spouse or child of an
honorably discharged veteran or an active-duty member of the U.S. military?
Yes
No
10. Does this person live with at least one child younger than age 19, and is this person the main person taking care of this
child(ren)?
Yes
No
Name(s) and date(s) of birth of child(ren)
11. Race (optional—check all that apply.)
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Korean
(complete Step 3 and Supplement B)
Cuban
Native Hawaiian
Asian Indian
Mexican, Mexican-American, or
Other Asian
Chicano
Black or African American
Other Pacific Islander
Puerto Rican
Chinese
Samoan
Other Hispanic/Latino/Spanish
Filipino
Vietnamese
Guamanian or Chamorro
White or Caucasian
Japanese
Other
Page 11
ACA-3 (Rev. 07/17)
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