Forms
The following forms can be completed online and then printed.
6 Month (Or Other Planned) IFSP Review Cover Sheet 51840
Acuerdo de Responsibilidad Personal 47971/FI 0010S
Application for Food Stamps, Cash Assistance, Health Coverage 30465/FI 2400
Allows anyone who wants to apply for Food Stamps, Cash Assistance (TANF) or Health Coverage (Medicaid) to file for any or all three programs, including emergency Food Stamps at any DFR office.
Application for Hoosier Healthwise for Children and Pregnant Women 43202/FI 2030
Application for Hospital Care to the Indigent 27097/FIHCI 0001
Used by individuals to apply for medical assistance to pay for inpatient hospital care provided as the result of an emergency condition.
Application for License to Operate a Child Placing Agency 47106/FPP 1425
Authorized Representative/Protective Payee for Hoosier Works Card 49884/FI 0024
Allows the TANF or Food Stamp recipient to grant permission to another person to be an Authorized Representative for Food Stamps or a Protective Payee for TANF, or both. The Authorized Representative or Protective Payee must also complete the form in order to receive a Hoosier Works card to access the client's benefits.
Changes to the IFSP 51841/BCD 0113
Child Care Center Narrative 46410/BCD 0078
Claim for Reimbursement Expenditures - Approved District Plans - Title 45529/FM 0411
Client Attendance Report - IMPACT Service Provider SF 47826(R/11-98)/IMP 0009
Client Member Authorization 51733/OMPP 0048 (Word Document)
Community Work Experience Program Job Request 46518/IMP 0001
Hoosier Healthwise Para Ninos & Mujeres Embarazadas - Hoosier Healthwise for Children and Pregnant Women - Spanish Version SF 48974(R2/3-03)/FI 2030S
IMPACT Memorandum 48330/IMP 0029
IMPACT Referral 46755/IMP 0004
Informe De Cambio 46777/FI 2420S
Used by Spanish speaking individuals to report changes in a family's or individual's circumstances that may affect eligibility for TANF, Food Stamps or Medicaid/Hoosier Healthwise benefits.
Initial Appointment for IMPACT 48895/IMP 0030
Notice of Action 1859/FI 0169C
Notice of Noncompliance with IMPACT (Employment and Training) Requirements 25285
Notice Regarding Rights and Responsibilities (Spanish Version) - State Form 48398 (R2/3-08) FI 0009S
Personal Representative Authorization 51732/OMPP 0047 (Word Document)
Personal Responsibility Agreement 47073/FI 0010
Personal Responsibility Agreement - Spanish Version SF 47971(R2/7-01)/FI 0010S
Record of Training, State Form 49708 (8-00)/FI 0005
Report of Change 44151/FI 2420
Used by TANF, Food Stamp, and Medicaid recipients to report address changes, household changes, income changes, and any other changes that may affect their benefits. Changes are required to be reported within 10 days.
Report of Repayment - Expenditures - Approved District Plans - Title 45531/FM 0413
Report on Complaint Filed 51735/OMPP 0050 (Word Document)
Request to Access Indiana Health Coverage 51731/OMPP 0046 (Word Document)
Self-Sufficiency Plan for IMPACT Client 47194/IMP 0002
These forms cannot be filled in online. They may be printed out and filled in by hand or typewriter.
Applicant Job Search Referral 48190/IMP 0019
Used by the local office of Family and Children for applicant of TANF & Food Stamps to determine if they are appropriate referrals for job search.
Applicant Job Search Rights and Responsibilities 48191/IMP 0020
Explains the rights and responsibilities to the TANF & Food Stamp recipients who are referred for a job search.
Application for Assistance - Part 3 - Client Certification and Assignment 47991/FI 2403
Assigns rights to medical support and child support for applicants for TANF, Food Stamps, and Medicaid. Requires signatures of applicant(s) attesting to their understanding of how they are to cooperate with policies of each program, and the consequences of non-cooperation.
Application for Assistance to Destitute Children 45097/DFC Form 319
Used to access resources that would allow a child to be placed outside the home temporarily without making the child a ward of the state, until a more permanent care arrangement can be made. This form is used by the current caregiver of a child whose parent(s) have died, are temporarily absent from the home or who have become incapacitated, leaving the child without appropriate care.
Application for Hoosier Healthwise for Children and Pregnant Women 43202/FI 2030
Used to apply for health coverage under Hoosier Healthwise for children under age 19 and pregnant women.
Application for Medicare Savings Program (QMB, SLMG, QI) 49228/FI 2033
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 (R/1-07)/FI 2033S (QMB, SLMB, QI) (Spanish Version)
Application for Voluntary Certificate of Recognition 49443/BCD 0034
Behavioral/Physical Health Coordination 51856/OMPP 0016
Checklist for Child Care Centers Health/Foods/Sanitation/Survey 45880/BCD 0038
Client Member Authorization 51733/OMPP 0048
Consent for Release of Information, State Form 53207 (6-07) FI 2511
Consent for Release of Information (Spanish Version), State Form 53318 (6-07) FI 2511S
Employability Plan 46205/IMP 0028
Used by TANF Control Group clients to list the action steps to assist clients to move toward self-sufficiency.
First Steps 30 Month Notice to Local Education Agency (LEA) 51673/BCD 0106
First Steps Transitional Meeting Minutes 51674/BCD 0107
Follow-Up Appointment for IMPACT 48894/IMP 0031
Healthcare Program for Childcare Centers 45877/BCD 0054
History of Immunizations 49445/BCD 0036
IMPACT Client Agreement 48419/IMP 0026
Explains IMPACT, TANF, or Food Stamp client's responsibilities for participation in Vocational Education or Job Skills Training.
IMPACT Report - Family Case Coordinator Monthly Referrals 47576/IMP 0011
Used by Family Case Coordinators to record TANF and Food Stamp referrals to providers.
IMPACT Referral 46755/IMP 0004
IMPACT Vocational or Job Skills Training - Financial Information 48418/IMP 0025
Used by Office of Family & Children and Training Providers to verify cost of Vocational or Job Skills Training.
Individual Family Transition Plan 51672/BCD 0105
Initial Assessment of Employability (page 1) 44713/DFC Form 2074
Initial Assessment of Employability (page 2) 44713p2
These two forms are used for assessment of employability for TANF and Food Stamp IMPACT clients.
Job Search Verification 48335/IMP 0022
Used by TANF and Food Stamp IMPACT clients doing individual job search. Contact with potential employers is recorded.
Master Job Application 48245/IMP 0021
Used by TANF and Food Stamp IMPACT clients seeking employment.
Member Access Request 51737/OMPP 0052
Member Accounting Request 51738/OMPP 0053
Notice of Action 35955/FIFS 0041
Notice of Action: Spanish 43351/FIFS 0041S
Notice of Action- Healthy Indiana Plan (HIP), State Form 53453 (11-07) HIP 2521
Notice Regarding Rights and Responsibilities 47990/FI 0009
Describes rights of individuals receiving TANF, Food Stamps, and/or Medicaid assistance and their responsibilities for complying with each program's requirements.
Parent's Notice 49444/BCD 0035
Personal Representative Authorization 51732/OMPP 0047
Reason for Delay of IFSP 51312/BCD 0089
Reciprocal Consent to Release and Share Information 51675/BCD 0108
Record Of Financial Eligibility Budget For Hoosier Healthwise SF 49422(2-00)/FI 0005B
Record of IMPACT Attendance 44720/IMP 2077
Used by TANF and Food Stamp IMPACT clients to record attendance or work required when participating in the IMPACT program.
Record of IMPACT Attendance - Multiple Activities 44721/IMP 2078
Used by TANF and Food Stamp IMPACT clients to record IMPACT attendance in multiple activities.
Record of Activity - IMPACT Service Provider 47578/IMP 0012
Used by IMPACT Service Providers to record participation in IMPACT components.
Report of Job Placement - IMPACT Service Provider 47579/IMP 0013
Used by IMPACT providers and local offices of Family & Children to record job placements.
Report on Complaint Filed 51735/OMPP 0050
Request by a Person or Organization for a Search of the State Central Registry 49214/FPP 0005
Allows Licensed Child Placing Agencies to request DFC to complete a CPS history on a specified person who wants to be a foster or adoptive parent.
Request for Authorization/Meeting Minutes 51839/BCD 0111
Request for Authorization for Transition Meeting/Transition Checklist 51670/BCD 0103
Request for Transportation 47300
Request for DFC to provide transportation for needed services, like visitation with a child by foster or biological parents, custodians, or caregivers.
Request to Access Indiana Health Coverage 51731/OMPP 0046
Researching the Occupation - Interview Questionnaire 48416/IMP 0023
Used by IMPACT, TANF & Food Stamp clients to research an occupation.
Researching the Vocational or Job Skills Training Program 48417/IMP 0024
Used by IMPACT, TANF & Food Stamp clients to research Vocational or Job Search Training Programs.
Revocation of Authorization 51736/OMPP 0051
Solicitud Para Asistencia Cupones Para Alimentos, Asistencia Financiera, Cobertura De Salud 48399/FI 2400S
Spanish version of the application for Food Stamps, Cash Assistance (TANF), or Health Coverage (Medicaid). All three programs may be applied for, including emergency Food Stamps.
Solicitud Para Asistencia - Parte 3 - Certificación del Cliente y Asignación 48400/FI 2403S
Spanish version of the final part of an individuals application for assistance.
Solicitud Para Hoosier Healthwise Para Niños & Mujeres Embarazadas 48974/FI 2030S
Spanish version of the application for health coverage under Hoosier Healthwise for children under age 19 and pregnant women.
Spanish version of the application for Medicare Savings Program for low income Medicare beneficiaries to help pay their Medicare Part B premium, coinsurance and deductibles.
Supplement to Health Program Form - Infant/Toddler 45878/BCD 0055
Transition Meeting Notification 51671/BCD 0104
Written Nutrition Food Service Program for Child Care Centers 46684/BCD 0051
Written Nutrition Food Service Program Infant/Toddler Child Care Centers 46682/BCD 0053
