Request For Authorized Representative Form
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1
2Commonwealth of Massachusetts
Department of Transitional Assistance
Request for Authorized Representative- Authorized
Agency-Authorized Payee
Office Name__________________________________________
____/____/_________
Date
Office Address________________________________________
____________________________________________________
SNAP Benefits
I authorize_____________________________________________to act as my representative for application
Print Name of Authorized Person
and recertification of SNAP benefits only.
I authorize_____________________________________________to act as my representative for transaction
Print Name of Authorized Person
of SNAP benefits only.
I authorize_____________________________________________to act as my representative for transaction
Print Agency Name
of SNAP benefits only. I___________________________________am authorized by the above
Print Agency Representative Name
agency to receive the EBT card that will be used for transaction of SNAP benefits only.
___________________________________________________________________________________
Administrative Office Address
I authorize_____________________________________________to act as my representative for both
Print Name of Authorized Person
application and recertification of SNAP benefits and transaction of SNAP benefits.
__________________________________________________
__________________________________________
Print Recipient’s Name
Recipient’s Telephone
___________________________________________ _______
__________________________________________
Recipient’s Signature
Recipient’s SSN
___________________________________________ _______
__________________________________________
Authorized Representative’s Signature or Agency
Authorized Representative’s SSN or Agency’s FEIN
Representative’s Signature
(for authorization only)
_____________________________________________________
Authorized Representative’s Date of Birth
__________________________________________________
__________________________________________
Worker’s Name
Worker’s Telephone
AR-P-1 (9/2005)
16-020-0905-05
Continued on back
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