Affidavit to Verify Residency

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.
Name

First nameMiddle initialLast name
Middle initial
Date of birth (MM/DD/YYYY)
Date of birth (MM/DD/YYYY)
Ref ID (optional)
Social Security number
MassHealth ID (optional)
STEP 2

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

I do not have a home address but intend to reside in Massachusetts. Mailing address:
State
ZIP
I do not have a home address but intend to reside in Massachusetts. Mailing address:
Street
City
ZIP
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
(MM/DD/YYYY)
(MM/DD/YYYY)
STEP 3
Return this signed form in one of these 3 ways.

2. Mail: Health Insurance Processing Center, P.O. Box 4405, Taunton, MA 02780
MassHealth Enrollment Centers
Health Connector Walk-in Centers
45 Spruce Street Chelsea, MA 02150 100 Hancock Street, 6th Floor Quincy, MA 02171 88 Industry Avenue, Suite D Springfield, MA 01104

21 Spring Street, Suite 4 Taunton, MA 02780 367 East Street Tewksbury, MA 01876 The Schrafft Center 529 Main Street, Floor M Charlestown, MA 02129
133 Portland Street Boston, MA 02114 63 Main Street Brockton, MA 02301 146 Main Street Worcester, MA 01608
Questions?
Call the Health Connector at (877) MA ENROLL, (877) 623-6765 or TTY: (877) 623-7773. Or call MassHealth at (800) 841-2900 or TTY: (800) 497-4648.
Should be Empty:

Affidavit to Verify

Massachusetts Residency

STEP 1

STEP 3

MassHealth Enrollment Centers

Health Connector Walk-in Centers

Questions?