Online Application Form


Before you Submit

Before submitting this application, did you…

  1. Attach a formal, written quote on a vendor’s company letterhead or a print out from a reputable source including the requested device or service and the total price including taxes, shipping, etc?

  2. Attach proof of income*?

    • If self-employed, attach your IRS tax returns (including all schedules) for the past two years.

    • If employed, attach two (2) months of your most recent pay stubs from your employer.

    • If you receive SSDI or SSI, attach your most recent award letter that you received showing your benefits income.

      *If you have additional income such as rental, child support, etc, acceptable documentation includes:

      • a) copies of court documents verifying this income

        and/or

      • b) copies of IRS tax returns (including all schedules) for the past two years.

  3. Attach a proof of Massachusetts residency? A copy of one of the following.

    • Driver’s license

    • Voter’s registration

    • Utility bill in your name

    • Non-driver’s ID

  4. Attach an acceptable documentation of disability? A copy of one of the following.

    • A signed doctor’s letter

    • SSDI or benefits award letter

  5. Complete all parts of the application?

    • If a question does not apply to you, write N/A or draw a line through that field so we know that you did not forget to answer any questions.

  6. Sign, initial, and date where required**?

    **If you have a power of attorney authorized to sign for you, please send the power of attorney document with this application.