Becoming an Authorized Representative

An applicant and or recipient may appoint or designate an individual or organization to serve as an Authorized Representative on their behalf. The individual or organization may assist with the application and/or renewal process and receive copies of notices for SNAP, cash and medical assistance.

An Authorized Representative (AR) must be knowledgeable of the individual’s circumstances. AR responsibilities include, but are not limited to: knowledge of income and resources and household composition and tax relationships.

Authorized representatives also assume responsibility for the accuracy of the information provided to the Division of Family Resources for applicants and must maintain confidentiality of all information provided.

Authorized representative forms are available on the HIP website http://www.in.gov/fssa/hip/2509.htm

  • Authorized Representative for Health Coverage (State Form 55366)
  • Authorized Representative for SNAP (Food Assistance) and Cash Assistance (State Form 53460)

The Authorized Representative form can also be generated from the following locations:

  • E signature after completion of the online application from the benefits portal.
    https://www.fssabenefits.in.gov/
  • Check status link in the Benefits Portal (only available for users whom are able to authenticate specific information concerning a case)
  • Request to mail a paper application from the Benefits Portal will include an Authorized Representative Form.

Each bar coded AR form is unique to a specific case, and copies should not be made of the form to attach to other cases, nor should the bar code be altered under any circumstances. The bar coded forms are unique to each case. This facilitates the attachment of the form to the appropriate case for expedient processing and provides better service to the AR and to the client.

During form completion, the Authorized Representative and the individual will determine their specific functions, which are either apply or ongoing.

Apply functions include:

  • Sign the application behalf of the applicant and represent the applicant during an interview
  • Provide all required verification to determine eligibility
  • Speak on behalf of the applicant at appeal

Ongoing functions include:

  • Reporting changes
  • Attending and/or assisting during redeterminations
  • Receiving notices

EBT (SNAP and TANF only) functions include:

  • Receiving Hoosier Works Card to access SNAP/Cash Benefits