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Family and Social Services Administration

DFR Home > Forms, Documents & Tools > Forms Forms

All Counties:
Fax to 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.


Bureau of Family Independence Forms (SNAP/Medical Assistance/Cash Assistance)

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.

Client Certification for Food Stamps 47991
Includes Food Stamp Work Registration requirements, a Certification section required to be signed and dated and an optional question pertaining to voter registration.

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

Bureau of Child Care Forms

Breast Milk Procedure 49954

Changes to the IFSP 51841

Child Care Center Narrative 46410

Application for License to Operate a Child Placing Agency 47106

6 Month (Or Other Planned) IFSP Review Cover Sheet 51840

Menu for Infants (8-12 Months) 49951

Menu for Toddlers 49952

Notice of Action 1859

Outcome Review 51838

Sample Menu for Infants (8-12 Months) 49950

Sanitation / Sterilization Procedures for Bottles, Nipples, Collars, Caps 49953

Self-Sufficiency Plan for IMPACT Client 47194

Checklist for Child Care Centers Health/Foods/Sanitation/Survey 45880

Health Care Program for Child Care Centers - Child Care Center Health Record 49969

Healthcare Program for Childcare Centers 45877

History of Immunizations 49445

Parent's Notice 49444

Reciprocal Consent to Release and Share Information 51675

Record of Medication Order 49968

Request for Authorization/Meeting Minutes 51839

Request for Authorization for Transition Meeting/Transition Checklist 51670

Supplement to Health Program Form - Infant/Toddler 45878

Supplemental Health Care Program for Child Care Centers - Providing Infant-Toddler Care-Hand washing Procedure 49961

Supplemental Health Care Program for Child Care Centers - Providing Infant-Toddler Care-Suggested Feeding Plan 49963

Supplemental Health Care Program for Child Care Centers - Providing Infant-Toddler Care-Weekly Record of Daily Needs 49960

Transition Meeting Notification 51671

Voluntary Certificate Program Checklist 49443

Written Nutrition Food Service Program for Child Care Centers 46684

Written Nutrition Food Service Program Infant/Toddler Child Care Centers 46682

 

Staff Only

You must be an FSSA staff member and be logged into the forms application to use these forms. To login, click on "Forms.IN.gov" on the right navigation under Online Services and then click on "State Employee Login". Fill in the blanks and click "OK".