Verification Chart

Proof you are currently meeting or were meeting ABAWD Work Rules through: 
If type = Enrollment in Education or Training Program:

• Completing the ABAWD Training Program Information Request form

If type = Working at least 20 hours per week or 80 hours per month:

• Proof of any pay you got in the last 4 weeks or if you expect a change, proof of the change:
• Pay stubs
• Letter from employer showing gross income and number of hours worked
• Proof that shows hours worked during the month(s) you were meeting

If you are self-employed then a signed letter telling DTA how many hours you work and:

• Schedule C (1040 IRS form)
• 1099 IRS form or
• Other tax record business record that show your income and business expenses

If type = Community Service:

• Completing the ABAWD Work Program Participation Report signed by the non-profit or public organization where you volunteer(ed), or;
• Other proof that you volunteer(ed) at a non-profit or public organization for the required number of hours in the month

• Statement from agency who took your application
• Letter or other official document

• This means they can sign DTA forms for you, report changes and speak to DTA about your case. We need a signed Request to Choose Someone to Be My Authorized Representative form.

If type = Authorized Representative – EBT:

• This means that the person you choose is allowed to transact your SNAP benefits. They will be issued an EBT card. We need a signed Request to Choose Someone to Be My Authorized Representative form.

If type = Authorized Representative – Agency:

• This means that the agency you choose is allowed to transact your SNAP benefits. They will be issued an EBT card.  We need a signed Request to Choose Someone to Be My Agency Representative for My SNAP Benefits form.

If type = Authorized Representative – Payee:

• This means that the person you choose is allowed to transact your cash benefits. They will be issued an EBT card.  We need a signed Request to Choose Someone to Be My Authorized Representative form.

• Current bank statement or other document showing account number and balance for any checking, savings, Certificates of Deposit or IRA
• If you no longer have the account: a letter from the bank saying the account is closed.

If you cannot access the account:
proof that you cannot access it.

• Policy or signed statement from seller
• Burial contract or trust cemetery plot deed

If you are self-employed:

• Records that show business expenses such as tax documents

If you have rental or roomer/boarder income:

• Your statement about how many hours per week you spend managing the rental unit(s) 
  and
• Proof of mortgage (including principal and interest)
• Bills for taxes, insurance, water, sewer, maintenance, and/or repairs
• Utility bills if you pay utilities for rental unit(s).

Or other related business expense.

Document showing you are exercising day to day care and control, such as:

• Court or school records
• Child protection agency documents

Although this is selectable on the Verification tab, staff must not utilize this verification element.

See Students for procedures on how to request verification of student eligibility.

Tell us this person’s date of birth. You can call to tell us or send us:

• Driver’s license or state issued I.D.
• Birth certificate or hospital birth record
• School, work or child care records
• Court or other government documents

• Death certificate
• Newspaper death notice
• Signed statement from funeral director Hospital or police records

We need more information about your dependent care costs:

• Self-declaration of expenses
• Statement or letter from provider
• Receipts canceled check or money order
• Statement about car mileage or other transportation costs to and from provider

Document showing you are the caretaker for a child, such as:

• Court or school records
• Child protection agency documents

• Proof that the disabled person lives in your home and
• A written statement from the physician of the disabled person you are caring for on their letterhead verifying:
• The person’s disability
• That they are in need of constant care and without your care that they would be institutionalized

Proof of any pay you got and hours worked for week(s) ending:

• {DATE}
• {DATE}
• {DATE}
• {DATE}

or if you expect a change, proof of the change:

• Pay stubs
• Letter from employer showing gross income and number of hours worked

If a new job your start date, hourly wage or salary and anticipated hours.

You told us that your job ended recently. We need to know how much you were paid during the last 4 weeks and any pay you will receive after your last day worked:

• Paystubs
• Letter from employer showing gross income and number of hours worked

Proof of disability such as:

• Disability based veterans benefits
• Eligibility for MassHealth based on disability or blindness
• Eligibility for disability based benefits due to blindness
• Other verifications of a physical or mental health problem that meets the federal standard of disability

Although this is selectable on the Verification tab, staff must not utilize this verification element.

See Students for procedures on how to request verification of student eligibility.

• Pay stub or other document

Statement from employer or agency that is garnishing money

Any document that shows good cause for not cooperating with child support, such as:

• Sign and return the Assignment of Support Rights
• Court, criminal, or law enforcement records
• Medical or psychological records
• Child protective services records
• Social service documents
• Statement from you and someone who knows about the reason for good cause

Proof you have a good cause reason for not pursuing custody or guardianship:

• Your signed statement saying why getting custody or guardianship would put you or the child at risk of serious harm, including emotional with as many details as you can give
  and
  Proof from someone who knows of the risk of harm such as:
• Records from law enforcement or court
• Statement from child protection agency, school or medical provider
• Detailed sworn statement from another person who knows the situation if no other proof is available

Official documents showing guardianship or custody, such as:

• Court records
• Child protection agency documents or proof that obtaining legal guardianship would place you or the child at risk of serious harm or emotional impairment.

We need more information about your shelter costs:
If you pay rent:

• {self-declaration,} rent receipt, lease, letter from your landlord, cancelled check or money order, Landlord Verification form, Shared Living form, or other document showing how much you are supposed to pay.
   If you own your home:
• {self-declaration,} mortgage statement, property tax, condo fees, home insurance bill or other document saying how much you are supposed to pay

We need more information about the type of housing you live in:
If program = TAFDC:

• Self-declaration
• Lease
• Letter from landlord
• Landlord Verification or Shared Housing Verification form
• Other document showing what type of housing you live in (private, public or subsidized)

If program = EAEDC:
Living Arrangement A:

• Copy of lease or mortgage
• Proof of other shelter cost
• Written statement from the family person you share housing costs with that explains how the costs are shared

Living Arrangement B:

• Written statement from the person you share housing costs with that explains how the costs are shared
• Self-declaration

Living Arrangement H:

• Written statement from the person you share housing costs with that explains how the costs are shared.

Living Arrangement C:
a written statement from an authorized person at the:

• Halfway house
• Licensed chronic hospital
• Approved public medical institution
• Licensed intermediate care facility
• Public psychiatric institution
• Residential treatment center
• where you are living

Living Arrangement D:

• A statement from an authorized person of the emergency shelter you are staying at
• Self-declaration of no housing costs.

Living Arrangement E:

• A written statement from an authorized person at the rest home.

Living Arrangement F:

• A written statement from an authorized person at the therapeutic community center

• Driver’s license or state issued I.D.
• Birth certificate or hospital birth record
• School, work or child care records
• Court or other government documents.
• Other documents that show who you are

• Immunization records
• Letter from medical provider
• Verification of Immunization Status form completed by medical provider
• Proof your child is enrolled in a Head Start, licensed day care program or school
• A written statement from you giving a religious reason for not immunizing your child

A written statement from a medical provider giving a health reason for not doing so.

Verifications: You told us you recently started or are about to start a job. We need information from your employer with:

• Anticipated start date
• How often you will get paid (weekly, bi-weekly, etc);
• How much you will make per hour; and
• Average number of hours per week or work schedule

If you are no longer going to start this new job you reported, please contact DTA right away.

• Inspection certificate or other proof that your home meets health and safety standards and/or
• Utility bill (for utility vendor payment only)

• Life insurance policy statement from issuing agency showing cash surrender value of policy

You have reported expenses that exceed your income. We need more information about this. Please provide proof of how you are meeting these expenses such as:

• Savings account
• Credit card statements

Other proof that shows what means you are supporting yourself by.

• Benefit or award letter
• Copy of payment document or check
• Letter from agency or person making the payment

If you spend any of this money on certain expenses, you may still be eligible for cash assistance. Ask DTA for details.

• Rent receipt, lease, or Landlord Verification form
• Deed or mortgage statement
• Shared Housing Verification form or statement from someone you live with
• Utility bill
• Voter registration

• Bills or receipts for medical costs not covered by MassHealth or other insurance, such as:
  • co-pays, premiums, and one time medical bills
  • prescription medication
  •  over-the-counter medical items
  • dental care or dentures
  • eyeglasses
  • hearing aid batteries
• Payments for homemakers, home health aides or other care you need
• Statement about car mileage or transportation costs to and from health appointments or pharmacy
• Documentation from your local Housing Authority  such as your annual rental summary

• Permanent Resident Card (“green card”)
• Employment Authorization Card
• Temporary Resident Card
• Arrival-Departure Record (I-94)
• Stamp in passport
• Other document showing current or pending immigration status

• A written statement from the Massachusetts Rehabilitation Commission of vocational disability including, participation in a program and its expected completion date
  and
  Copy of MRC’s medical and/or psychological reports qualifying for MRC services

• Documents showing value of pension, IRA, Keogh, 401k or other retirement accounts or
• Proof you cannot access these accounts

Any document that shows this person is in the home, such as:

• Lease, Landlord Verification form or letter from your landlord saying who lives with you
• Shared Housing form or letter from the person you live with saying who lives with you.
• School or child care records
• Child welfare or court records
• Mail addressed to this person at your address
• Voter registration

Other document showing this person lives with you.

Any document that shows this person is not in the home, such as:

• Proof this person lives somewhere else
• Lease, Landlord Verification form or letter from your landlord saying who lives with you
• Shared Housing form or letter from the person you live with saying who lives with you.
• Divorce, child support order or other court records
• Proof of death

• Most current business records
• Most current tax returns
• Paid receipts that show the type of expense amount
• Pay stubs
• Letter from employer showing gross income and number of hours worked
• Letter from employer stating last date worked and last date paid
• Wages stubs or written letters from employers showing gross income for the past four weeks
• Other

• Disability Supplement: fill out this form to tell us about your health problems. Tell us if you need help with the form
  and
• Medical Report: Give this to your doctor (or other medical provider listed on this form) to fill out. Tell us if you need help or do not have a doctor

If EAEDC or TAFDC Only,

• Self-Declaration of your insurer’s name, your policy number, and your group number
• A Copy of your insurance card
• Any Letters, bills, and statements from your insurers
• Business records or other statements indicating health insurance coverage
• Other Documentation from your Health Care Provider
•   If SNAP only:
• Any Letters, bills, and statements from your insurers showing the amount you pay for health insurance
• A Copy of your paystub, showing the amount that you pay for health insurance, which would be deducted from your paycheck
• Business records or other statements indicating health insurance cost
• Other Documentation from your Health Care Provider showing your health insurance premium amount.
• Telling us about health insurance premiums and medical expense costs may increase your SNAP benefits. You can submit proof of these any time.
• If Combo (TAFDC/EAEDC and SNAP) and the individual is an elderly and/or disabled member
• Any Letters, bills, and statements indicating health insurance coverage (i.e., your policy number and group number) and showing the amount you pay for health insurance
• A Copy of your insurance card or a paystub, showing the amount that you pay for health insurance and indicating health insurance coverage
• Business records or other statements indicating health insurance coverage and your out-of-pocket costs
• Other Documentation from your Health Care Provider indicating health insurance coverage and showing your health insurance premium amount
• Telling us about health insurance premiums and medical expense costs may increase your SNAP benefits. You can submit proof of these any time.
• If Combo (TAFDC/EAEDC and SNAP) and the individual is not an elderly and/or disabled member:
• Self-Declaration of your insurer’s name, your policy number, and your group number
• A Copy of your insurance card
• Any Letters, bills, and statements from your insurers
• Business records or other statements indicating health insurance coverage
• Other Documentation from your Health Care Provider

• Current tax bill
• Written appraisal
• Proof you are trying to sell this property
• Proof that you legally cannot sell the property

• A copy of the benefit or award letter
• A copy of the check or payment document; or
• A written statement from the agency or person making the payment

You told us you want to give permission for DTA to discuss your case information with an agency or person. We need a:

• Signed, dated statement from you telling us the name or agency you want us to share information with

• Schedule E (1040 IRS form)
• Records that show how much you get for rent from your tenant or roomer/boarder:

Lease agreement or written statement from the tenant showing the amount of rent paid

You told us you lost food purchased with your SNAP benefits due to a disaster or other misfortune. We need:

• Signed Statement of Loss/Request for Replacement Food Due to a Household Disaster or Misfortune
  and

Proof of the loss such as a letter from a utility company confirming loss of power or from the fire department if the loss was due to a fire

• Learnfare Attendance Report for Schools
• Verification from school showing number of unexcused absences

To show that unexcused absences should be excused, you can give us:

• Proof of illness from medical provider
• Your written statement of illness if your child didn’t miss more than 4 days of school in a row
• Hospitalization records
• Proof the child case has disability
• Proof of family crisis or emergency
• Statement about observed religious holidays

Proof showing enrollment, full or part-time status, and expected date of completion such as:

• Report card
• Letter from the school
• School Verification form

This information may make a dependent teen’s earnings not count against your benefits and may prove an exemption from work activities.

• Schedule C (1040 IRS form)
• 1099 IRS form or other tax record
• Business record that show your income from self-employment

We need more information to prove you are exempt from the General Work Rules.
If type = Unable to Work - Illness or Temporary Disability, display:

• You told us that you have a temporary illness or disability that prevents you from working.  You can tell us by calling the DTA Assistance Line at 877-382-2363 to verify your temporary illness or disability over the phone, or you can provide a written self-declaration indicating one of the following:
• You are receiving services or ever received services in the past from Massachusetts Commission for the Blind, Massachusetts Commission for the Deaf and Hard of Hearing or the Department of Developmental Services;
• You are disabled or have a health problem that prevents you from working, that is expected to last 90 days (3 months) or more.  This includes mental, physical, sensory, learning, intellectual, cognitive, or developmental, or;
• You are actively participating in services from Massachusetts Department of Mental Health or MassAbility and your illness/disability is expected last 90 days (3 months) or more.

If type = Caretaker, display:

• You told us that you are a caretaker for a child under 6 years old or a caretaker for a disabled adult.  You can tell us by calling the DTA Assistance Line at 877-382-2363 to verify your Caretaker exemption over the phone, or you can provide a written self-declaration indicating you are a caretaker for someone under the age of 6 or a disabled adult.  The self-declaration must include if they live with you or not.
• You can also have a family member provide a written letter stating you are their family member’s caretaker if that’s easier for you.

If type = Substance Use Treatment, display:

• You told us that you are participating in a Substance Use Treatment Program.  You can tell us by calling the DTA Assistance Line at 877-382-2363 to verify your exemption over the phone, or you can provide a written self-declaration indicating you are participating in a Substance Use Treatment Program.  
• You can also have the Substance Use Treatment Program write a letter to verify you are actively participating in the program if that’s easier for you.

• Proof of Social Security Disability or SSI benefits
• Disability-based medical coverage
• Veteran’s disability benefits
• Other proof of federally certified disability

• Tell us this person’s Social Security Number. You can call and tell us

If this person doesn’t have a Social Security Number, proof that this person has applied for one

• Your statement about the number of stocks and bonds you own, and
• Any documentation showing the current value of stocks or bonds or
• Proof you cannot access the stocks and bonds

• Tax return
• Court ordered support; or
• Other official government forms

• Medical documentation
• Documents from a job, school, institution or agency
• Return travel ticket

If you will be absent more than 30 days, we also need:

• Current rent or utility bill
• Other proof you intend to keep your Massachusetts residency

• A signed release of information for DTA to contact the state where you last received benefits
• Closing letter or other document showing you are no longer get assistance in another state

• Receipts or documents showing how you spent the assets

If you spent any of this money on certain expenses, DTA won’t count that amount as part of the lump sum. Ask DTA for details.

• Benefit or award letter
• Check, or record of payment
• Statement from agency making payments

• Benefit or award letter
• Statement from agency making payments

• self-declaration
• Bill for heat, air conditioning, electricity, gas or phone
• Bill for other utility costs such as coal, wood for heating, garbage collection, water and sewer
• Lease showing you pay for utilities
• Letter from landlord or roommate.

• Veterans Vendor Payments Form (VVPF)
• Letter from Landlord
•  Letter from VA or any other source

• Self-declaration
• School or child care records
• Medical records
• Child welfare or court records
• Lease, Landlord Verification form or letter from your landlord saying who lives with you
• Shared Housing form or letter from a person you live with saying who lives with you
• Statement from someone who knows where you live