- DFR: Administrative appeal & hearing request form
- DFR: Authorized representative for health coverage form
- DFR: Authorized representative for SNAP (food assistance and cash assistance)
- DFR: Authorization for disclosure of personal and health information
- DFR: Becoming an authorized representative
All Counties
Fax: 888-436-9199 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.
Indiana Application for SNAP and Cash Assistance (state form 53263)
Indiana Application for SNAP and Cash Assistance (Spanish) (state form 53622)
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)
Claim to Defray Funeral and Cemetery Expenses SF 35937
Applicant Job Search Rights and Responsibilities 48191
Explains the rights and responsibilities to the TANF & SNAP recipients who are referred for a job search.
IMPACT Client Attendance Report - Vocational Education Training / Job Skills Training 47826
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465
Notice Regarding Rights & Responsibilities for Health Coverage 55367
Notice Regarding Rights and Responsibilities for Health Coverage (Spanish) 55372
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461
Authorized Representative for Health Coverage (Spanish) 55371