Massachusetts Department of Transitional A. Important: Please Read Before Completing

Transcription

1 9/15/2015 Document Te t DTA - DPC P.O. Box 4406 Taunton, Ma Massachusetts Department of Transitional A BOSTON MA /11/2015 Important: Please Read Before Completing You have received this letter because: You have told us that you have moved; or The U.S. Postal Service has told us that you have moved. Department mail is not forwarded by the post office. You must tell us within 10 days of a change in your address and phone number. You must verify where you live. Please complete the section below telling us your address and phone number and give us proof of your Massachusetts residency. Acceptable verifications include but are not limited to: lease, rent receipt, statement from landlord, two pieces of mail r Address where you live City, State Zip: Mailing Address: City, State Zip: Telephone Number Type (Please Circle One) ( ) Home Cell Work Other ( ) Home Cell Work Other Attached is a pre-printed address and household verification form in two parts. Part 1: "Current Household Information" shows your current information and part 2: "Change Report Form" will show us changes to the information. Please review the information on Part 1. If the information provided is correct select "No Change" in the boxes provided, then sign and return the entire form. If there is a change, please select "Change" in the boxes provided and make the change in the appropriate section of the "Change Report Form". You must also give us proof of that change by 09/21/2015. Please call DTA if you have questions about this notice. Your benefits may be stopped if you do not return this notice. You will r to notice if your benefits are going to be stopped. JD=BNFDC&ACTION=viewDocument& iuk=zg9jswq9oteznzuxmjcmc3nvvg9rzw5jrd... 1/6

2 Important: See Your Benefits Online: You may get information about your DTA benefits online. Sign up for My Account Page (MAP) at will let you check the status of your case, your benefit level and see recent notices. You can print your own verification of benefits. You can also call the DTA Automated Hotline at DTA: FAX: RETURNEDMAILNOTICE Agency ID: 2 hhs.state.nn a.us/nn ap/control ler Servl erpageid=bnfdc&action= vi ewdocument& i uk=zg9j SW Q9OT EzNzUxMj cm c3n vvg9rzw 5JRD... 2/6

3 PART 1: CURRENT HOUSEHOLD INFORMATION Review the information provided. If the information is correct select No change.. If the information is not correct, you need to report a change select change and make the change in the appropriate section of the attached form. SECTION 1: PEOPLE IN HOUSEHOLD Household Member Date of Birth SSN No Change Change Enter a change in Section 1 of Change Report If a person(s) has moved into or left your household please enter the change in Section 1 of the Change Report Form. SECTION 2: SHELTER EXPENSES AND TYPE Household Member Type of Housing Expense Frequency Amount Rent Monthly $0.00 SECTION 3: UTILITY EXPENSES Household Member Type of Utility Expense For DTA Purposes Only Heating/Cooling H-EAT Benefits 9/2014 No Change Change Enter a change in Section 2 of Change Report No Change Change Enter a change in Section 3 of Change Report What you pay for utilities is separated into groups Utility Group I pay for heat, or I get fuel assistance. Heating/Cooling I pay for electric and I have an air conditioner that I use in the Summer. Heating/Cooling I do not pay electric, but I have an air conditioner that I use in the Summer and my landlord charges me a fee. Heating/Cooling I pay electric. Nonheating I pay for a phone (including cell phones, but not prepaid). Telephone I do not pay any separate utilities. I Not Applicable (N/A) SECTION 4: Additional Information Change If you feel you have a change of circumstances that was not listed on the Current Household Information section of this report please let us know by completing the additional information section (Section 4 of the change report form.) You may also tell us about any concerns or questions you have in this section of the report. RETURNEDMAILNOTICE Agency ID: i uk=2g9j SW Q9OT EzNzUxMj cm c3n vvg9rzw 5JRD... 3/6

4 9/15/2015 Document Te PART 2: Change Report Form Please use this part of the Report to r t changes from the information you just reviewed on the previous page in the "Current Household Information" section. Pay close attention to when verifications are requested for that change. SECTION 1: PEOPLE IN HOUSEHOLD If you are adding a new member(s), please verify identity. Acceptable verifications include: member's Social Security number (you only have to supply the number do not send SSN card), birth certificate, passport, or baptismal certificate. The person(s) listed below is now a member of my household Name DATE MOVED IN DATE OF BIRTH SSN* RELATIONSHIP TO YOU US Citizen Circle Answer YES NO I I I YES NO Does this person(s) purchase food and/or prepare meals separately fr f these people pay towards your rent or utilities? YES NO If you answered Yes to the questions above: Please explain the breakdown and arrangement: The person(s) listed below no longer lives with me. Name Date Moved Out SECTION 2: SHELTER EXPENSES AND TYPE Acceptable verifications include: Current rent receipt, Landlord Verification form or lease agreement, mortgage statement, tax or home insurance bills. You may self-declare shelter expenses by entering the changed amounts below for SNAP benefits only; however, you may be required to provide proof of shelter cost changes if the changes appear to be questionable or contradictory to prior statements you have made. Household Member Type Rent Mortgage Taxes Insurance 'Condominium Fees Frequency of payment py (Weekly, Monthly, Yearly, etc.) Amount Do you live in subsidized housing? Do you live in public housing? Yes No Yes No RETURNEDMAILNOTICE Agency ID: ttps://service.hhs.state.rna.us/rnap/controllerservle ID=BNFDC&ACTION=viewDocument& iuk=2g9jswq9oteznzuxmjcmc3nvvg9rzw5jrd... 4/6

5 SECTION 3: UTILITY EXPENSES You may self-declare utility expenses by entering the changed amounts below; however, you may be required to provide proof of utility cost changes if the changes appear to be questionable or contradictory to prior statements you have made. Acceptable verifications include: Current bills for gas, electric, oil or telephone, landlord statement, rent r lease. t, or Household Member Type of Utility Expense I pay to heat my home (oil, gas, electricity or propane, etc.) or share heating costs with others. I have an air conditioner that I use in the summer, and I pay for electricity or share costs with others. I have an air conditioner that I use in the summer, and I pay a fee to use it. I, or someone in my SNAP household, got help with heating costs from a fuel assistance agency within the last 12 months. I pay for electricity or gas or share this cost with others. I pay for phone service, including cell phone service (not a pre-paid phone). SECTION 4: ADDITIONAL INFORMATION Circle Answer Voter Registration: If you have not r tered to vote at your current address and would like to do so, check the box below. Registering to vote or declining to register will not affect your eligibility. 111 I w Id like DTA to mail a voter registr tion form to me at my new address. enotification: If you have not registered for enotification and would like to do so, check the box below. enotification is a faster way to see notices about your DTA benefits. If you have a working address and register for a My Account Page (MAP) account you can opt to get enotification. If you don't already have a MAP account, you can create one at If you choose to participate in enotification DTA will continue to mail forms to you that must be completed. However, these forms also will be available on your MAP account and can be printed. I would like receive enotifications. My address I I is: Please use this section to report any additional information that you feel may affect your benefit or to express any concerns or questions you may have. If you are reporting changes, please make sure you: Sign and Date this change report form. If you are reporting changes include any required verification. Return this entire Form to: DTA P.O. Box 4406, Taunton MA EID=BNFDC&ACTION=viewDocument& i uk=2g9j SW Q9OT EzNzUxMj cm c3n vvg9rzw 5JRD... 5/6

6 I certify under penalty of perjury under the laws of the United States of America and the Commonwealth of Massachusetts that the above information is true, correct and complete. X Applicant Signature Date RETURNEDMAILNOTICE Agency ID: 2 Close a.us/nn ap/control ler Servl e ID=BNFDC&ACTION=viewDocument& iuk=2g9jswq9oteznzuxmjcmc3nvvg9rzw5jrd... 6/6