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Verification Chart

For all DTA programs, certain information, such as income, or immigration status for any member listed on the application who is not a U.S. citizen, are considered mandatory verifications. Proving this information is required in order to determine eligibility. Other information however, like dependent care or housing expenses, are considered optional verifications, meaning they are not required to establish eligibility, but if verified, may result in a higher benefit amount.

The following chart is a guide to identify which information is considered mandatory, optional, or not applicable for each benefit program. The chart also identifies examples of verification that clients may provide. An item may appear more than once on a VC-1 for an individual with multiple sources of the same item. For example, bank accounts, or Earnings and Number of Hours Worked will appear twice for an individual with multiple bank accounts or earnings from multiple employers. These items are displayed separately to provide additional clarity for the client of what specific proofs we are requesting.

M =  Mandatory

O = Optional

N/A = Not Applicable to the benefit program

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes

SNAP ABAWD Work Rules Participation
(Participation Type)

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
 O n/a n/a  
Agreement to Reimburse DTA Complete and sign the Authorization for Reimbursement of Interim Assistance form. n/a n/a M  
Application for Other Benefits
 (Other Application Type)		 You have to apply for other benefits DTA thinks you might be eligible for. We need proof that you applied:
  • Statement from agency who took your application
  • Letter or other official document
 n/a M M  

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Assisting Person (Representative Type) You told us you want to give permission to someone to be a Representative.
If type = Authorized Representative – Application:
  • 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.
 O O O  
Bank Account
(Institution Name)
(Account Type)
(Account Number)
  • 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.

 M* N/A N/A * Must only request if SNAP non- categorically eligible or EAEDC rest home AU's, otherwise not applicable
Burial Insurance or Prepaid Funeral Agreement
  • Policy or signed statement from seller
  • Burial contract or trust cemetery plot deed
 n/a M M  
Business Expenses

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.

 O O O  
Care and Control

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

  • Court or school records
  • Child protection agency documents
 n/a M n/a  
Caring for a Disabled Person in Your Home Verification of Caring for Disabled form: Give this to the disabled person’s doctor (or other medical provider listed on this form) to fill out. n/a O n/a  
Cash on Hand Written statement of how much cash you have available. n/a M M Preferred method is Telephonic Self-declaration
Child Support Cooperation Sign and return the Absent Parent Affidavit and the Assignment of Support Rights. n/a M n/a  
Child Support Legal Obligation Documents showing a legal obligation to pay child support such as a court order to someone outside of your household. O* n/a n/a *Not subject to Reverification
Clarification of Social Security Number Examples of Verifications You May Provide M* M* M* * Not subject to Reverification

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Exemption from SNAP ABAWD Work Rules: Unable to Work – DTA Determination

We need more information to prove you are exempt from the ABAWD Work Rules.

You stated you are experiencing a health problem that limits you from working/training 30 or more hours per week. This could be due to mental, physical, sensory, learning, intellectual, cognitive, developmental, substance dependency or as a victim of domestic violence, sexual harassment, sexual assault or stalking.

Please provide a letter from your medical provider stating that you are unable to work 30 or more hours per week due to experiencing one of the reasons stated above.

 O n/a n/a  
Exemption from SNAP ABAWD Work Rules: Indian per IHCIA

We need more information to prove you are exempt from the ABAWD Work Rules.

You stated that you are an American Indian or Alaska Native as described in the Indian Health Care Improvement Act.

Please provide one of the following acceptable forms of verification:

  • Tribal enrollment or membership card
  • Certificate of Degree of Indian/Alaska Native Blood (CDIB)
  • Letter from the Bureau of Indian Affairs (BIA) or tribal government
  • Documentation reflecting an Interior or HHS determination
  • Proof of residence in the urban center (e.g., ID, lease, mail) plus evidence meeting one of the criteria’s above.
  • Letter/card from an IHS‑funded Urban Indian Organization confirming eligibility as an “eligible urban Indian.”
  • Official tribal letter acknowledging membership of or descent from Indians residing in California on June 1, 1852;
  • Proof of trust/allotment interests such as:
    • patents or deeds;
    • Probate Inventory Report;
    • IIM (Individual Indian Money) account statement;
    • BIA-approved lease, mortgage, or other LTRO-recorded instrument; or
    • BIA Title Status Report (TSR)
 O n/a n/a  
Exemption from SNAP ABAWD Work Rules: Pregnant

We need more information to prove you are exempt from the ABAWD Work Rules.

You told us you are pregnant.

Please provide a letter or document from your medical provider or from an organization stating you are pregnant and your anticipated due date, if known.

If you are unable to obtain proof of pregnancy from your medical provider or an organization, you can submit a signed statement stating you are pregnant and your anticipated due date, if known.

 O n/a n/a  
Date of Birth

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
 M* M* M* * Not subject to Reverification
Date of Death
  • Death certificate
  • Newspaper death notice
  • Signed statement from funeral director Hospital or police records
 M* M* M* * Not subject to Reverification
Dependent Care Costs

We need more information about your dependent care costs:

Dependent Care Provider Costs:

  • Statement or letter from the child or adult care provider showing the amount that you are responsible for
  • Receipts, canceled check, or money order

If you drive the person to and from the dependent care provider:

  • Statement or self-declaration stating the address of the provider and how often you drive to and from this provider.

If you pay for any other transportation costs to bring the person to the dependent care provider:

  • Parking or tolls receipts
  • Statement or receipts from a transportation company (e.g., Lyft, Uber) or for public transportation (e.g., bus, subway, taxi, The RIDE)

 

 O O O  

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Direct Deposit Form The Direct Deposit form completed and signed by you.
If there is a good reason why you don’t want to be on direct deposit, let DTA know.		 n/a O* O*  
Disability of Elder Noncitizen SNAP Disability Verification form: Give this to your doctor (or other medical provider listed on this form) to fill out. M* n/a n/a * SNAP Disability Verification form needs to be updated each year.
EAEDC Caretaker Family

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

  • Court or school records
  • Child protection agency documents
 n/a n/a M  
EAEDC Caring for Disabled
  • 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
 n/a n/a M  
Earnings and Number of Hours Worked
(Employer Name)

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.

 M M M  
Earnings from a Job That Ended
(Employer Name)

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
 M* M* M* * Not subject to Reverification.
Effort to Become a US Citizen Proof that you applied to become a U.S. citizen such as a copy of the application or a letter from your lawyer
Proof that you are enrolled in a citizenship or English class
Proof that a community agency or lawyer is helping you pursue citizenship
Tell us if there is a good reason that you can’t pursue citizenship.		 n/a n/a M* *Only for EAEDC with LPR status.
Federally Certified Disability

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
 O O n/a  

Student Eligibility

You told us that you or someone in your household is a college student. You must send us any documentation verifying that the student:

  • receives MassGrant: such as a Financial Aid Award letter
  • is anticipating to participate or actively participating in work study: such as pay stubs or a letter from the college
  • is participating in an on-the-job training program: such as a letter from the employer
  • is enrolled in an employment and training program limited to remedial courses, basic adult education, literacy, or English as a Second Language (ESL): such as a letter from the program they attend
  • is placed in an employment and training program through the Workforce Innovation and Opportunity Act (WIOA): such as a letter from the institution or MassHire Career Center
  • was placed in an employment and training program through Trade Adjustment Assistance (TAA): such as a letter from MassHire Career Center or a letter from the Department of Unemployment Assistance (DUA) confirming that they were approved for TAA training
  • is mentally or physically unfit for employment: such as a letter from the student’s physician/certified psychologist stating the student is physically or mentally unfit for employment or a letter from the college/university’s Accommodation’s Office or Disability Access Office stating that the student receives additional support
 M M n/a  
Financial Aid and School Enrollment Information We need you and your Financial Aid Office to complete the Educational Income and Expense Form. M M n/a

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.
Foster Care Official document showing the foster care placement of the person in your care. n/a M M  
Garnishment Amount and Reason for Garnishment
(Garnished Income Type)		 We need to know how much is being garnished and what it is being garnished for:
  • Pay stub or other document

Statement from employer or agency that is garnishing money

 O O O  
Good Cause for Not Cooperating with Child Support

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
 n/a O n/a  

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Good Cause for Not Meeting the SNAP ABAWD Work Rules We need more information that you had or are having a crisis or emergency situation during the month(s) of:
{MONTH}
{MONTH}
{MONTH}
Please submit a letter giving us details about the situation and include how long it lasted or is expected to last, or you can call the DTA Assistance Line at 877-382-2363 to tell us about your good cause.		 O n/a n/a Preferred method is Telephonic Self-declaration
Good Cause for Not Pursuing Custody or Guardianship

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
 n/a n/a O  
Guardianship or Custody

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.
 n/a M M* *Mandatory for EAEDC only after 6 months from date of application or most recent EAEDC reevaluation.
Housing Costs

We need more information about your shelter costs:

If you pay rent:

  • rent receipt, lease, letter from your landlord, cancelled check or money order, Landlord Verification form, Shared Living form, or other document showing the exact amount you are supposed to pay.
    • If you are not the primary tenant or the homeowner, provide a statement from the person you live with stating what your share of the shelter and utility expenses are.

If you own your home:

  • mortgage statement, property tax, condo fees, home insurance bill or other document saying the exact amount you are supposed to pay
 O O O  

Housing Costs – Group Homes

We need more information about your shelter costs:

Please have your group home's Agency Representative complete the enclosed Agency Certification of Shelter Expenses Form (FS-ACSE), or provide any of the following:

  • rent receipt, lease, letter from your landlord, cancelled check or money order, Landlord Verification form, Shared Living form, or another document showing how much you are supposed to pay
 O O O *Only generated for cases with a group home address type in BEACON and do not have verified shelter expenses
Housing Type (Living Arrangement)

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
 n/a M* M* Preferred method is Telephonic Self-declaration
* Not subject to Reverification.
Identity
  • 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
 M* M* M* *Mandatory only if a new head of household or authorized rep. Required again at reapplication for a grantee who has been closed or denied for 1 calendar year or longer. Otherwise not subject to re-verification
Immunization
  • 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.

 n/a M* n/a *Only allowable for children in the TAFDC AU who are pending or active. Not applicable for dependents who are ineligible due to noncitizen status, or SSI.
Income You Get From Someone Who Rooms/ Boards with you Records that show how much you get from your roomer/boarder. M M M  

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Information About a New Job

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.

 M* M*  M* *Information is User Entered only
Information so DTA can pay your rent and/or utility bill from your cash benefits
  • Inspection certificate or other proof that your home meets health and safety standards and/or
  • Utility bill (for utility vendor payment only)
 n/a O* O* *User selectable as Mandatory or Optional.
Life Insurance
  • Life insurance policy statement from issuing agency showing cash surrender value of policy
 n/a n/a M* *Mandatory for Rest Home cases only
Living Above Means

You have reported housing and/or dependent care expenses that exceed your income.  We need more information about this.

If you are meeting these expenses, provide proof of how you are meeting them by submitting verification(s) such as:

  • Savings, Checking, Retirement account statements
  • Credit card statements
  • Personal Loan statements
  • Income withdrawn from financial assets, such as 401(k) account, Traditional IRA, Roth IRA Dividend or Capital Gain distribution statements
  • Payments from community-based organizations, mutual aid, or other assistance programs such as RAFT, HomeBASE, or Go Fund Me.
  • Other proof that shows what means you are supporting yourself by

Or

If you are not meeting these expenses, provide verification(s) such as:

  • Proof of how much rent/mortgage you owe; and/or
  • Proof of how much dependent care expenses you owe
  • Proof of payment plan
     
 M M M  
Lump Sum Payment
(Lump Sum Type)
  • 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.

 n/a M M  
Massachusetts Residency
  • 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
 M* M* M* * Not subject to Reverification.
Medical Costs
  • Bills or receipts for medical costs not covered by MassHealth or other insurance, such as:
    • health insurance co-pays and premiums
    • 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
  • Documentation from your local Housing Authority such as your annual rental summary

If you drive to your medical appointments and/or the pharmacy:

If you pay for any other transportation costs:

  • Parking or tolls receipts
  • Statement or receipts from a transportation company (e.g., Lyft, Uber) or for public transportation (e.g., bus, subway, taxi, The RIDE).
 O n/a n/a  
Noncitizen Status
  • 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
 M* M* M* * Not subject to Reverification.
Other Assets Documents showing the value of the asset and proof you cannot access the asset. M* n/a M* * Must only request if SNAP non- categorically   eligible or EAEDC rest home, otherwise not applicable
Participation in a Mass Rehabilitation Commission Program
  • 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
 n/a n/a M  
Past Due Housing Costs Verification of how much rent/mortgage you owe. O M* M* Preferred method is Telephonic Self-declaration
*Mandatory if misuse of benefits is presumed based on screening or ongoing SLAM
Past Due Utility Costs Verification of how much you owe on your utility bill(s). O M* M* Preferred method is Telephonic Self-declaration
*Mandatory if misuse of benefits is presumed based on screening or ongoing SLAM

Past Exemption from SNAP ABAWD Work Rules

We need more information to prove you were exempt from the ABAWD Work Rules in {MONTH}. Please provide proof that you met the exemption listed below. The verification must state the date the exemption started and ended (if applicable) so that the Department can remove your strike(s).

If Value = General Work Rules: Unable to Work – Certified Disability, display:

You told us you have a federal disability.  Please provide proof of the disability such as:

  • A letter from SSA showing you are federally certified as disabled.
  • A letter from the Department of Veterans Affairs, MA Department of Veterans Services, or another state Veterans Services agency showing you are 100% disabled.
  • A letter or other document showing you are disabled through MassHealth standards.
  • A letter or other document showing eligibility for disability benefits due to blindness.
  • Verification of a physical or mental health condition that meets the federal standard of disability.

If Value = General Work Rules: Unable to Work – Temporary Illness or Disability, display:

You told us that you had a temporary illness or disability that prevented 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 had a health problem that prevented 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 were actively participating in services from Massachusetts Department of Mental Health or MassAbility and your illness/disability is expected to last 90 days (3 months) or more.

If Value = General Work Rules: Caretaker, display:

You told us that you were a caretaker for a child under 6 years old or a caretaker for a person with a disability.

If you cared for a child under the age of 6, and they are not part of your SNAP household, you must provide a letter from the child’s parent/guardian stating you cared for the child and if you received any pay.

If you cared for a person with a disability, have the medical provider of the person you cared for complete the enclosed SNAP Caring for a Person with a Disability Form or provide a letter from the person’s medical provider stating that that this person needs consistent care.

If Value = General Work Rules: UC Applicant/Recipient, display:

You told us you applied for or were receiving unemployment compensation.  Please provide proof of the pending unemployment compensation application, the benefit or award letter, or a check/record of payment from The Department of Unemployment Assistance.

If Value = General Work Rules: Student, display:

You told us you were a student.  You must send us any documentation verifying that you:

  • received MassGrant: such as a Financial Aid Award letter
  • participated in work study: such as pay stubs or a letter from the college
  • participated in an on-the-job training program: such as a letter from the employer
  • were enrolled in an employment and training program limited to remedial courses, basic adult education, literacy, or English as a Second Language (ESL): such as a letter from the program you attend
  • were placed in an employment and training program through the Workforce Innovation and Opportunity Act (WIOA): such as a letter from the institution or MassHire Career Center
  • were placed in an employment and training program through Trade Adjustment Assistance (TAA): such as a letter from MassHire Career Center or a letter from the Department of Unemployment Assistance (DUA) confirming that you were approved for TAA training
  • were mentally or physically unfit for employment: such as a letter from your physician/certified psychologist stating you were physically or mentally unfit for employment or a letter from the college/university’s Accommodation’s Office or Disability Access Office stating that you received additional support

If you were participating in a training program, you must provide proof, such as a letter from the school showing you were enrolled at full or part time status, what the training was intended for, and the date of completion.

If Value = General Work Rules: Substance Use Treatment, display:

You told us that you were participating in a substance use treatment program. Please have the substance use treatment program write a letter to verify you were actively participating in the program.

If Value = ABAWD: Unable to Work – DTA Determination, display:

You stated you were experiencing a health problem that limited you from working/training 30 or more hours per week. This could be due to mental, physical, sensory, learning, intellectual, cognitive, developmental, substance dependency or as a victim of domestic violence, sexual harassment, sexual assault or stalking.

Please provide a letter from your medical provider stating that you were unable to work 30 or more hours per week due to experiencing one of the reasons stated above.

If Value = ABAWD: Indian Per IHCIA, display:

You stated that you are an American Indian or Alaska Native as described in the Indian Health Care Improvement Act.

Please provide one of the following acceptable forms of verification:

  • Tribal enrollment or membership card
  • Certificate of Degree of Indian/Alaska Native Blood (CDIB)
  • Letter from the Bureau of Indian Affairs (BIA) or tribal government
  • Documentation reflecting an Interior or HHS determination
  • Proof of residence in the urban center (e.g., ID, lease, mail) plus evidence meeting one of the criteria’s above.
  • Letter/card from an IHS‑funded Urban Indian Organization confirming eligibility as an “eligible urban Indian.”
  • Official tribal letter acknowledging membership of or descent from Indians residing in California on June 1, 1852;
  • proof of trust/allotment interests such as:
    • patents or deeds;
    • Probate Inventory Report;
    • IIM (Individual Indian Money) account statement;
    • BIA-approved lease, mortgage, or other LTRO-recorded instrument; or
    • BIA Title Status Report (TSR)

If Value = Pregnant, display:

You told us you are/were pregnant.

Please provide a letter or document from your medical provider or from an organization stating you are/were pregnant and your anticipated due date, if known.

If you are unable to obtain proof of pregnancy from your medical provider or an organization, you can submit a signed statement stating you are/were pregnant and your anticipated due date, if known.
 

 O n/a n/a *User-Entered only
Pathways to Self-Sufficiency Employment Development Plan Please review, sign and return your entire Pathways to Self-Sufficiency Employment Development Plan. n/a M* n/a *Mandatory only for non-exempt clients only at application and reevaluation. Otherwise Optional.
Payment of Child Support Proof of payment. O O n/a  
Pension and Retirement Accounts
  • Documents showing value of pension, IRA, Keogh, 401k or other retirement accounts or
  • Proof you cannot access these accounts
 M* n/a M* * Must only request if SNAP non-categorically eligible or EAEDC rest home, otherwise not applicable.
People who Joined Your Household

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.

 n/a M M Preferred method is Telephonic Self-declaration
People who Moved Out of Your Household

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
 n/a M M Preferred method is Telephonic Self-declaration
Potential Earnings - DOR
  • 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
 M n/a n/a  
Pre-Benefit  Job Search Form (Initial Job Search Client) You must complete and return the PBJS  Initial Job Search log. n/a O n/a  
Pre-Benefit  Job Search Form (Work Ready Client) You must complete and return the PBJS Work Ready log. n/a M n/a  
Pregnancy Letter or document from your medical provider saying you are pregnant and what your due date is. O M* M *Not subject to Reverification. Mandatory for TAFDC if no other dependents are in the households hold.
Proof of Disability, Physical or Mental Health Problem for EAEDC
  • 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
 n/a n/a M* *Mandatory only for EAEDC applicants and clients under age 65 applying as a disabled person , or with a residential facility type of rest home.
Proof of Disability, Physical or Mental Health Problem for TAFDC Good Cause Medical Statement: Give this to your doctor (or other medical provider listed on the form) to fill out. Tell us if you need help or do not have a medical provider. n/a O n/a  

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Proof of Disability, Physical or Mental Health Problem From Medical Provider for TAFDC Good Cause Medical Statement: Give this to your doctor (or other medical provider listed on the form) to fill out. Tell us if you need help or do not have a medical provider. n/a O n/a
Proof of Health Insurance

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
  
Property value (other than home they live in)
  • Current tax bill
  • Written appraisal
  • Proof you are trying to sell this property
  • Proof that you legally cannot sell the property
 M* n/a M* * Must only request if SNAP non- categorically eligible or EAEDC rest home only, otherwise not applicable
Reevaluation form Please review, sign and return your entire reevaluation. n/a M M  
Refunds
  • 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
 M n/a n/a  
Release of Information

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
 O O O  
Removal of Heightened Level of Security You have told us you want to remove Heightened Level of Security. We need a:
Signed Request to Remove Heightened Security		 O* O* O* *Not subject to Reverification.
Rental Income
  • 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

 M M M  
Request for Deduction from EBT Account Form EBT-4. O O O  
Request for an Extension of Time Limited Benefits Please review, sign and return your entire Review Summary/Extension Request and Agreement form. n/a O n/a  
Request for Heightened Level of Security You have told us you want to have Heightened Level of Security. This means you will only be able to speak with DTA and access your case in-person. We need a: Signed Request for Heightened Level of Security O* O* O* *Not subject to Reverification.
Request for a Replacement Check Form FCB-1. n/a O O  
Request for Replacement SNAP Benefits

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

 O n/a n/a  
Request for School Employee Information  Request for School Employee Information (RSEI-1) Form 
Contract from School
Letter from School Other		 M M M  
School Attendance in (Month) Monthly Learnfare Attendance Report
Verification from school showing the number of unexcused absences for the month
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		 n/a M n/a  
School Attendance from (Month) to (Month)
  • 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
 n/a M n/a  
School/Training Enrollment

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.

 O O O  
Self-Employment Income and Number of Hours Worked
  • Schedule C (1040 IRS form)
  • 1099 IRS form or other tax record
  • Business record that show your income from self-employment
 M M M  
SNAP General Work Rules Exemption – Unable to Work – Illness or Temporary Disability

We need more information to prove you are exempt from the General Work Rules.

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 to last 90 days (3 months) or more.
 O  n/a n/a  

SNAP General Work Rules Exemption – Caretaker

We need more information to prove you are exempt from the General Work Rules. 

You told us that you are a caretaker for a child under 6 years old or a caretaker for a person with a disability. 

If you are caring for a child under the age of 6, and they are not part of your SNAP household, you must provide a letter from the child’s parent/guardian stating you care for the child and if you receive any pay. 

If you are caring for a person with a disability, have the medical provider of the person you are caring for complete the enclosed SNAP Caring for a Person with a Disability Form or provide a letter from the person’s medical provider stating that that this person needs consistent care. 		O n/a n/a  

SNAP General Work Rules Exemption – Substance Use Treatment

We need more information to prove you are exempt from the General Work Rules.

You told us that you are participating in a Substance Use Treatment Program.  Please have the Substance Use Treatment Program write a letter to verify you are actively participating in the program.

 O n/a n/a  
Social Security Disability
  • Proof of Social Security Disability or SSI benefits
  • Disability-based medical coverage
  • Veteran’s disability benefits
  • Other proof of federally certified disability
 O M M  
Social Security Number or Proof of Application
  • 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

 M* M* M* *Permanent Verification.
Stocks and Bonds
  • 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
 M* n/a M* * Must only request if SNAP non- categorically eligible or EAEDC rest home only, otherwise not applicable
TAFDC Work Program We need proof that you have met your work program hours for 2 weeks. If you have questions about what activities count or think you have a good reason why you can’t meet those hours tell DTA right away. n/a M n/a  
Tax Dependents Proof of your tax dependents such as:
  • Tax return
  • Court ordered support; or
  • Other official government forms
 O O O  
Temporary Absence Proof that absence is temporary such as:
  • 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
 n/a M M  
Termination of Benefits in Another State You told us you were receiving benefits in another state in the last 30 days. We need:
  • 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
 M M M  
Transferred Asset
  • 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.

 M* n/a M* * Must only request if SNAP non- categorically eligible or EAEDC Rest Home only, otherwise not applicable.

Item

Examples of Verifications The Client May Provide

SNAP

TAFDC

EAEDC

Notes
Trust Fund Trust fund  documents or
Proof you cannot access the trust fund		 M* n/a M* *Must only request if SNAP non- categorically eligible or EAEDC rest home only, otherwise not applicable
U.S. Citizenship For SNAP and TAFDC:
Self-declaration
Birth certificate or hospital birth record
U.S. Passport
Certificate of naturalization
Other government documents showing U.S. citizenship
For EAEDC:
Birth certificate or hospital birth record
U.S. Passport
Certificate of naturalization
Other government documents showing U.S. citizenship.		 M* M* M* *Not subject to Reverification.
Unearned Income
(Unearned Income Type)		 You told us you have unearned income. We need proof of the amount, how often it is paid and who it is paid to:
  • Benefit or award letter
  • Check, or record of payment
  • Statement from agency making payments
 M M M
Unearned Income that has ended
(Unearned Income Type)		 You told us you have unearned income that has ended. We need proof of the amount you last received and the date you were paid:
  • Benefit or award letter
  • Statement from agency making payments
 M M M
Utility Costs We need more information about your utility costs:
  • 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
 O O O
Veterans Vendor Payments
  • Veterans Vendor Payments Form (VVPF)
  • Letter from Landlord
  •  Letter from VA or any other source
 O O n/a
Who you live with
  • 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
 n/a M* M* *Not subject to Reverification.
Your Relationship to: Records showing how you are related such as:
Birth certificate or adoption papers
Marriage certificate
Child protection or court records
Child care or school records or
Other records showing relationship		 n/a M* M* *Not subject to Reverification.
Additional Verification Examples of Verifications You May Provide {free form text} * * * * User Entered. You must mark as Mandatory or Optional.

Related Topics

Verifications Policy and Procedures - EAEDC

Verifications Policy and Procedures - TAFDC

Last Update: August 10, 2026

 

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