Form Image-10 "Request to Choose Someone to Be My Authorized Representative" - Massachusetts

What Is Form Image-10?

This is a legal form that was released by the Massachusetts Department of Transitional Assistance - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Massachusetts Department of Transitional Assistance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form Image-10 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Transitional Assistance.

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Download Form Image-10 "Request to Choose Someone to Be My Authorized Representative" - Massachusetts

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Give this form to DTA
By Mail: DTA Document Processing Center,
Request to Choose Someone to Be My
P.O. Box 4406, Taunton, MA 02780-0420
By Fax: (617) 887-8765
Authorized Representative
Upload to the DTA Connect App
In person at your local DTA office
_________________________________________________
__________________________________________________
Client Name
Last 4 Digits of SSN or Agency ID
_______________________________________________________________________________________________________
Client’s Residential Address
Important Points to Remember
The same person may be named for multiple roles.
You can cancel or change this request at any time.
EBT cards still work if a case reopens after being closed. If you don't want the person you choose to get and
use your benefits, be sure to tell DTA to cancel their card.
o
For SNAP only clients, please call the DTA Assistance line at (877) 382-2363.
o
For TAFDC/EAEDC clients, please call your cash worker directly.
Section A – Designating a SNAP Authorized Representative for Certification and/or EBT Transactions
 I choose ______________________________ to be my SNAP Authorized Representative for Certification. His/her phone
number is ______________________________. This person can sign my SNAP paperwork or any other forms, report
changes and talk about my case with DTA. If I get too many benefits because s/he gave DTA the wrong information, I may
have to pay DTA back.
 I choose ______________________________ to be my SNAP Authorized Representative for EBT Transactions. This
person will receive an EBT card if s/he gives DTA proof of identity. S/he can buy food for me using my SNAP benefits. I will
also get my own EBT card.
Section B – Designating a TAFDC/EAEDC Authorized Representative and/or Authorized Payee
 I choose ______________________________ to be my TAFDC/EAEDC Authorized Representative. This person can report
changes and talk about my case with DTA. If I get too many benefits because s/he gave DTA the wrong information, I may
have to pay DTA back.
 I choose ______________________________ to be my TAFDC/EAEDC Authorized Payee. This person will receive an EBT
card if s/he gives DTA proof of identity. S/he can get money from my TAFDC or EAEDC account for me. I will also get my
own EBT card.
___________________________________
______________________________________
_____/_____/__________
Client or Legal Guardian Name (Print)
Client or Legal Guardian Signature
Date
Note for SNAP Cases: Court appointed guardians signing on behalf of a client must attach a copy of the Guardianship
Decree with this form.
Helping agencies that are not acting as an authorized representative should provide the Voluntary Consent to Release
Information (VARI-OI) or similar form.
This institution is an equal opportunity provider.
Image-10 (Rev. 12/2018)
16-020-1218-05
Give this form to DTA
By Mail: DTA Document Processing Center,
Request to Choose Someone to Be My
P.O. Box 4406, Taunton, MA 02780-0420
By Fax: (617) 887-8765
Authorized Representative
Upload to the DTA Connect App
In person at your local DTA office
_________________________________________________
__________________________________________________
Client Name
Last 4 Digits of SSN or Agency ID
_______________________________________________________________________________________________________
Client’s Residential Address
Important Points to Remember
The same person may be named for multiple roles.
You can cancel or change this request at any time.
EBT cards still work if a case reopens after being closed. If you don't want the person you choose to get and
use your benefits, be sure to tell DTA to cancel their card.
o
For SNAP only clients, please call the DTA Assistance line at (877) 382-2363.
o
For TAFDC/EAEDC clients, please call your cash worker directly.
Section A – Designating a SNAP Authorized Representative for Certification and/or EBT Transactions
 I choose ______________________________ to be my SNAP Authorized Representative for Certification. His/her phone
number is ______________________________. This person can sign my SNAP paperwork or any other forms, report
changes and talk about my case with DTA. If I get too many benefits because s/he gave DTA the wrong information, I may
have to pay DTA back.
 I choose ______________________________ to be my SNAP Authorized Representative for EBT Transactions. This
person will receive an EBT card if s/he gives DTA proof of identity. S/he can buy food for me using my SNAP benefits. I will
also get my own EBT card.
Section B – Designating a TAFDC/EAEDC Authorized Representative and/or Authorized Payee
 I choose ______________________________ to be my TAFDC/EAEDC Authorized Representative. This person can report
changes and talk about my case with DTA. If I get too many benefits because s/he gave DTA the wrong information, I may
have to pay DTA back.
 I choose ______________________________ to be my TAFDC/EAEDC Authorized Payee. This person will receive an EBT
card if s/he gives DTA proof of identity. S/he can get money from my TAFDC or EAEDC account for me. I will also get my
own EBT card.
___________________________________
______________________________________
_____/_____/__________
Client or Legal Guardian Name (Print)
Client or Legal Guardian Signature
Date
Note for SNAP Cases: Court appointed guardians signing on behalf of a client must attach a copy of the Guardianship
Decree with this form.
Helping agencies that are not acting as an authorized representative should provide the Voluntary Consent to Release
Information (VARI-OI) or similar form.
This institution is an equal opportunity provider.
Image-10 (Rev. 12/2018)
16-020-1218-05