Give this form to DTA Massachusetts Department of ...

Massachusetts Department of Transitional Assistance

Financial Assistance Form

Instructions

Give this form to DTA By Mail: DTA Document Processing Center,

P.O Box 4406, Taunton, MA 02780-0420 By fax: (617) 887-8765 Upload to the DTA Connect App In person at your local DTA office

DTA needs more information about the money you regularly receive from someone outside of your household. You can use this form or ask the person providing the money to write a letter that includes: the amount of money you receive, how often they give you the money and what the money is used for.

If you have any questions or are unable to get this information, please call DTA at 1-877-382-2363.

Part A: Completed by the client.

_____________________________________ Client Name

______________________________ Agency ID or last 4 of SSN

Part B: Completed by the person who helps financially.

I, ____________________________________ give _____________________________ financial assistance.

Name of Person Giving Money

Client Name

Please fill out all that apply:

Rent

Expense

How much?

How often?

Who receives this payment? (Ex. Landlord, Utility Co., Mary Smith)

Mortgage

Condo fee

Property taxes

Property Insurance

Heat (oil, gas or propane)

Electricity

Gas Phone Other (see below)

If other is selected, please explain what it is used for: _________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________ Name of Person Giving Money

__________________________ Signature

__________ Date

FA-1 (10/2017) 25-020-1217-05

This institution is an equal opportunity provider.

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