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Family and Social Services Administration

Family and Social Services Administration

DFR Home > Forms, Documents & Tools > Forms Forms

All Counties
Fax: 1-800-403-0864 or deliver or mail to your local county office.

If you do not see the form you are searching for in the sections below, you can search the state forms library.


Indiana Application for SNAP and Cash Assistance (state form 53263)

Indiana Application for SNAP and Cash Assistance (Spanish) 53622

FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530)

Revocation of Authorization 51736

Protective Payee for Hoosier Works Card 49884
Allows the TANF recipient to grant permission to another person to be a protective payee for TANF. The protective payee must also complete the form in order to receive a Hoosier Works card to access the client's TANF benefits.

Application for Medicare Savings Program (QMB, SLMG, QI) 49228
Used to apply for the Medicare Savings Program for low income Medicare beneficiaries to help pay their Medicare Part B premium, coinsurance and deductibles.

Application For Medicare Savings Program SF 49921  (QMB, SLMB, QI) (Spanish version)

Application and Claim for Funds to Defray Burial Costs - Medicaid, Aged, Blind and Disabled Recipients 35937

Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514

Applicant Job Search Rights and Responsibilities 48191
Explains the rights and responsibilities to the TANF & SNAP recipients who are referred for a job search.

IMPACT Client Attendance Report - Vocational Education Training / Job Skills Training 47826

IMPACT Client Attendance Report - Vocational Education Training / Job Skills Training (Spanish) 54586

IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049

IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465

Notice Regarding Rights & Responsibilities for Health Coverage 55367

Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372

Authorized Representative for SNAP (food assistance) and Cash Assistance 53460

Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461

Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105

Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance (Spanish) 54106

Authorized Representative for Health Coverage 55366

Authorized Representative for Health Coverage (Spanish) 55371