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Salutation
-- Mr. Mrs. Ms. Miss Mr. and Mrs. Dr. Prof. Senator Gov. Congressman Hon. Fr. Sister Rabbi Reverend Admiral Commander Colonel General Lieutenant Lt. Col. LCDR Major Private Sergeant Petty Officer

First Name

Middle Name / Initial

Last Name

Street Address

Street Address (2)

City

State
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County

Zip Code

Email Address

Verify Email Address

Daytime Phone

Evening Phone

Mobile Phone

Personal Representative

If you are a Personal Representative making an inquiry on someone else's behalf, please provide your contact information so that we may contact you directly.

First Name

Last Name

Email Address

Daytime Phone

Inquiry Details

Please describe your problem/inquiry and how you would like the senator to help.

Type of assistance for which applied (food stamps, Medicaid, TANF, etc.)

Application Date

Case Number

Date of Birth

Privacy Release

If you would like for the senator and his/her legislative staff to make inquiries on your behalf and receive details of the state agency's response to your concern, please complete the contact information section of the Disclosure Authorization form and return it with your signature. This form is not required for making an inquiry and can be returned via email, fax or postal mail.

Email: s40@iga.in.gov
Fax: 317-234-9201
Mail: State Senator Mark Stoops, 200 W. Washington St., Indianapolis IN 46204