Online Application Form
Before you Submit
Before submitting this application, did you…
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?
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
b) copies of IRS tax returns (including all schedules) for the past two years.
Attach a proof of Massachusetts residency? A copy of one of the following.
Utility bill in your name
Attach an acceptable documentation of disability? A copy of one of the following.
A signed doctor’s letter
SSDI or benefits award letter
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.
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.