Appendix C: Important DTA Forms and Charts
DTA Forms
- Request to Choose Someone to be my Authorized Representative
- Request for an Appeal(Fair Hearing)
- DTA Medical Expense Self-Declaration Statement
MLRI Information and Sample Forms
- SNAP Mandatory Verifications Chart
- Links to SNAP Know Your Rights fliers and additional SNAP resources
- Sample Client Consent Allowing DTA to release Information to Helping Agency
- Sample Client Declaration of Shelter and Dependent Care Costs
MLRI's SNAP Math At a Glance Charts
- At-a-Glance Chart on SNAP for Working Households
- At-a-Glance Chart for Unemployment Comp Households
- At-a-Glance Chart for 1 and 2 Persons Elder/Disabled Households
- SNAP Benchmarks Chart for Claiming Medical Expenses
Attachment | Size |
---|---|
2 DTA Authorization- Consent.pdf (129.27 KB) | 129.27 KB |
3 rqst to choose authorized rep.pdf (160 KB) | 160 KB |
4 Apppeal reguest-ENGLISH.pdf (555.77 KB) | 555.77 KB |
7 SNAP Verifications Chart- 2019 Guide final.pdf (186.13 KB) | 186.13 KB |
Verifications- FAX Cover Sheet March 2013.pdf (34.16 KB) | 34.16 KB |
appendix-c-sample-client-declaration-of-shelter-and-child-care-costs.pdf (389.45 KB) | 389.45 KB |
Working Households - SNAP At-A-Glance Chart (3).docx_0.pdf (90.2 KB) | 90.2 KB |
Unemployed Households SNAP At-A-Glance Chart- Updated January 2023_0.pdf (76.44 KB) | 76.44 KB |
Older Adults and Disabled Households SNAP At-A-Glance Chart_0.pdf (76.77 KB) | 76.77 KB |
SNAP and Medical Expenses Benchmark Chart_0 (1).pdf (61.64 KB) | 61.64 KB |
SNAP Know Your Rights fliers and additional SNAP resources.pdf (96.2 KB) | 96.2 KB |