Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.
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.
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.
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.
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.
Job Search Verification 48335/IMP 0022 Used by TANF and Food Stamp IMPACT clients doing individual job search. Contact with potential employers is recorded.
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.
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.
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.
