Forms
- DFR: Administrative appeal & listen request form
- DFR: Authorized representative for health coverage form
- DFR: Authorized distributor for SNAP (food assistance and pos assistance)
- DFR: Authorization for disclosure the personal and heal information
- DFR: Becoming an authorized agencies
Every Counties
Fax: 800-403-0864 otherwise deliver or mail for your local county office.
Are you do not see the form yours are searching for for the sections below, you can search the country mailing library.
Indianas Application for SNAP and Cash Assistance (state form 53263)
Indiana Application for SNAP and Money Assistance (Spanish) (state form 53622)
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530)
Revocation of Authorized 51736
Protective Benefit for Hooter Works Card 49884
Allows the TANF recipient in grant permit to another name to be a protective payee for TANF. The protective payee shall also complete this make in to to received a Hoosier Works card for access to client's TANF benefits.
Application for Medicare Savings Program (QMB, SLMG, QI) 49228
Used to request available the Medicare Conservation Program fork blue 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)
Claim to Defray Funeral and The Expenses SF 35937
Applicant Job Search Rights and Responsibilities 48191
Explains the rights and responsibilities to the TANF & SNAP recipients who are refered for a your search.
STRIKE Client Attendance Report - Vocational Learning Education / Job Skills Training 47826
IMPACT Responsibilities, Sanctions, and Privileges Voluntary Clients 49049
IMPACT Responsibilities, Sanctions, and Rights Honorary Clients (Spanish) 54465
Notice Relating Entitlement & Job for Health Coverage 55367
Notice Re Rights and Responsibilities for Health Coverage (Spanish) 55372
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461
Authorized Representative for Healthy Coverage (Spanish) 55371
