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Luzia

This document is an affidavit for verifying Massachusetts residency, requiring the applicant to provide personal information and confirm their intent to reside in the state. It includes instructions for submitting the form and emphasizes the importance of truthfulness under penalty of perjury. The document also provides contact information for assistance and submission options.

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gketlen390
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32 views1 page

Luzia

This document is an affidavit for verifying Massachusetts residency, requiring the applicant to provide personal information and confirm their intent to reside in the state. It includes instructions for submitting the form and emphasizes the importance of truthfulness under penalty of perjury. The document also provides contact information for assistance and submission options.

Uploaded by

gketlen390
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Affidavit to Verify

Massachusetts Residency
When you send us this form, please include a copy of the letter that we sent you asking for proof of your
Massachusetts residency status. The letter is called a “Request for Information.”

STEP 1 Tell us about yourself. Please print.

First name Luzia Middle initial A Last name Pereira


Ref ID
Date of birth (MM/DD/YYYY) 1 / 1 / 1990 (optional)
(857)272-5726
MassHealth ID
Social Security number
(optional)

STEP 2 Read and sign this form.

! I live at the following address and intend to reside in Massachusetts.


Residential address:
595 Main Street
Street ..................................................................................... Medford
City ................................................ M ZIP .....................
State ......... 02155

! I do not have a home address but intend to reside in Massachusetts. Mailing address:
595 Main Street
Street ..................................................................................... Medford
City ................................................ M
State .......... 02155
ZIP ......................

I am not visiting Massachusetts for personal pleasure or to receive medical care in a setting other than a nursing home.
By signing below, I swear under the pains and penalties of perjury that everything on this form is true and complete
to the best of my knowledge. I know that if I lie on this form, my health coverage might end and I might have to repay
Massachusetts for any tax credits or health benefits I got.

Applicant, member, or authorized representative signature


Date
 (MM/DD/YYYY) / /

STEP 3 Return this signed form in one of these 3 ways.

1. FAX: (857) 323-8300


2. Mail: Health Insurance Processing Center, P.O. Box 4405, Taunton, MA 02780
3. In person:

MassHealth Enrollment Centers Health Connector Walk-in Centers


45 Spruce Street 21 Spring Street, Suite 4 133 Portland Street
Chelsea, MA 02150 Taunton, MA 02780 Boston, MA 02114
100 Hancock Street, 6th Floor 367 East Street 63 Main Street
Quincy, MA 02171 Tewksbury, MA 01876 Brockton, MA 02301
88 Industry Avenue, Suite D The Schrafft Center 146 Main Street
Springfield, MA 01104 529 Main Street, Floor M Worcester, MA 01608
Charlestown, MA 02129

Call the Health Connector at (877) MA ENROLL, (877) 623-6765 or TTY: (877) 623-7773.
Questions?
Or call MassHealth at (800) 841-2900 or TTY: (800) 497-4648.
AFF-MR (10/19)

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