Massachusetts SNAP Benefits Application

Step 1 of 11

Personal Information

Tell us about yourself — this is the basic identifying information for your application.

Your Name

First Name *

Middle Name (optional)

Last Name *

Contact & Address

Home Address *

City, State, Zip Code *

Mailing Address (if different)

Mailing City, State, Zip

Phone Number

Are you homeless?

Text Message Preference

I do not want DTA to send me text messages

Step 2 of 11

Signature & Date

Upload a PNG image of your signature. This will be placed on the form where your signature is required.

By signing, you certify that all information in this application is true and complete to the best of your knowledge. Providing false information can result in criminal prosecution.

Upload Signature Image

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Click to browse or drag & drop your signature image here

PNG format recommended (JPG also accepted)

Application Date

Date *

Step 3 of 11

About You

Demographic and eligibility information. Race and ethnicity questions are optional and do not affect eligibility.

Identity

Social Security Number

Date of Birth

Gender

Are you pregnant?

Are you a U.S. Citizen?

Preferred Language

Race (optional — does not affect eligibility)

Black or African American American Indian or Alaska Native White Asian Native Hawaiian or Other Pacific Islander

Ethnicity (optional)

Hispanic or Latino Not Hispanic or Latino

Step 4 of 11

Disability & EBT Card

EBT Card

Do you currently have a Massachusetts EBT card?

Disability

Are you a person with a disability?

Impairment type(s) — check all that apply:

Physical Hearing Visual Intellectual / Cognitive Emotional / Mental Health

Has Massachusetts certified that you have a disability?

Preferred method of communication:

In-Person Telephone Video Relay Services (VRS)

VRS Phone Number

Step 5 of 11

Household Members

Only list your spouse, children under age 22, and others who buy and make the majority of meals with you.

Do other people live with you in your household?

Maximum 4 household members can be listed on the form.

Step 6 of 11

Income

Report income for everyone in your household.

Earned Income

Has anyone in your household worked in the last 60 days?

Other Income

Examples: Unemployment, Child Support, Social Security, SSI, Veterans' Benefits, Pensions, Rental Income.

Does anyone receive any other type of income?

Step 7 of 11

Shelter & Utility Costs

Shelter Costs

Is your household responsible for shelter costs (rent, mortgage, etc.)?

Rent

Monthly Amount ($)

Frequency

Mortgage

Monthly Amount ($)

Frequency

Utility Costs

Is your household responsible for utility costs?

Heat (oil, gas, electricity, propane, etc.) Electricity and/or gas (non-heating) Electricity for air conditioner (summer) Fee to use air conditioner (summer) Phone or cell phone service

Step 8 of 11

Dependent Care Costs

Is anyone responsible for adult or child care costs?

Step 9 of 11

Medical Costs

For household members who are at least 60 years old and/or disabled.

Medical costs include co-pays, prescriptions, over-the-counter medications, health insurance, medical bills, transportation, and more. You can get credit even if you're behind or can't pay.

Does anyone who is at least 60 or disabled have out-of-pocket medical expenses?

Step 10 of 11

SNAP Work Program

Information about work, training, and volunteer activities for household members.

Is anyone in a training program at least 80 hours/month?

Is anyone working in exchange for goods/services (in-kind work)?

Is anyone doing an unpaid internship?

Is anyone volunteering?

Has anyone received SNAP benefits outside Massachusetts in the past 30 days?

Step 11 of 11

Representatives & Submit

Optionally authorize someone to assist with or manage your case.

Assisting Person / Agency

May DTA contact someone if they can't reach you?

Name

Phone

Address

Authorization to Release Information

Allow someone to speak with DTA and access your case information?

Name

Phone

Address

Authorized Representative for Certification

Allow someone to sign forms, report changes, and manage your case?

Name

Phone

Federal Employer ID (agencies only)

Authorized Representative for EBT Transactions

Allow someone to use an EBT card to shop for you?

Name

Phone

Address

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Your completed SNAP Benefits Application has been generated.
Download it, then follow the steps below to submit.

How to Submit

📬 Submit to DTA

Email: DTAConnect@mass.gov
Fax: 617-887-8765
Mail: DTA Document Processing Center, P.O. Box 4406, Taunton, MA 02780
In person: Scan at any local DTA office
Phone: 877-382-2363 (Mon–Fri, 8:15am–4:45pm)

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