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Family and Social Services Administration

• 6 Month (Or Other Planned) IFSP Review Cover Sheet 51840
• Acuerdo de Responsabilidad Personal 47971
• Application and Claim for Funds to Defray Burial Costs - Medicaid, Aged, Blind and Disabled Recipients 35937
• Application for Hoosier Healthwise for Children and Pregnant Women 43202  
• Application for License to Operate a Child Placing Agency 47106
• Authorized Representative/Protective Payee for Hoosier Works Card 49884
  Allows the TANF or SNAP (food assistance) recipient to grant permission to another person to be an Authorized Representative for SNAP 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. *
• Changes to the IFSP 51841
• Child Care Center Narrative 46410
• Client Attendance Report - IMPACT Service Provider SF 47826  *
• Client Member Authorization 51733  *
• Community Work Experience Program Job Request 46518
• Cover Letter for FI0014 and FI0065 49769
• First Steps Early Intervention System Documentation of Receipt of Rights/Consent to Proceed/Permission to Assess 51842
• Hoosier Healthwise Para Ninos & Mujeres Embarazadas - Hoosier Healthwise for Children and Pregnant Women - Spanish Version SF 48974
• Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514
• Informe De Cambio 46777
  Used by Spanish speaking individuals to report changes in a family's or individual's circumstances that may affect eligibility for TANF, SNAP (food assistance) or Medicaid/Hoosier Healthwise benefits.
• Initial Appointment for IMPACT 48895 *
• Notice of Action 1859
• Notice of Noncompliance with IMPACT (Employment and Training) Requirements 25385
• Outcome Review 51838
• Personal Representative Authorization 51732 * (Word Document)
• Personal Responsibility Agreement 47073*
• Personal Responsibility Agreement - Spanish Version SF 47971
• Report on Complaint Filed 51735
• Request to Access Indiana Health Coverage 51731
• Self-Sufficiency Plan for IMPACT Client 47194

These forms cannot be filled in online. They may be printed out and filled in by hand or typewriter.

• Applicant Job Search Referral 48190
  Used by the local office of Family and Children for applicant of TANF & SNAP (food assistance) to determine if they are appropriate referrals for job search.
• Applicant Job Search Rights and Responsibilities 48191
  Explains the rights and responsibilities to the TANF & SNAP (food assistance) recipients who are referred for a job search.
• Application for Assistance - Part 3 - Client Certification and Assignment 47991
  Assigns rights to medical support and child support for applicants for TANF, SNAP (food assistance), 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
  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.
• Application for Hoosier Healthwise for Children and Pregnant Women 43202
  Used to apply for health coverage under Hoosier Healthwise for children under age 19 and pregnant women.
• 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 for Voluntary Certificate of Recognition 49443
• Behavioral/Physical Health Coordination 51856
• Checklist for Child Care Centers Health/Foods/Sanitation/Survey 45880
• Client Member Authorization 51733
• Employability Plan 46205
  Used by TANF Control Group clients to list the action steps to assist clients to move toward self-sufficiency.
• First Steps 30 Month Notice to Local Education Agency (LEA) 51673
• First Steps Transitional Meeting Minutes 51674
• Follow-Up Appointment for IMPACT 48894
• Healthcare Program for Childcare Centers 45877
• History of Immunizations 49445
• IMPACT Client Agreement 48419
  Explains IMPACT, TANF, or SNAP (food assistance) client's responsibilities for participation in Vocational Education or Job Skills Training.
• IMPACT Report - Family Case Coordinator Monthly Referrals 47576
  Used by Family Case Coordinators to record TANF and SNAP (food assistance) referrals to providers.
• IMPACT Referral 46755
• Individual Family Transition Plan 51672
• Job Search Verification 48335
  Used by TANF and SNAP (food assistance)  IMPACT clients doing individual job search. Contact with potential employers is recorded.
• Master Job Application 48245
  Used by TANF and SNAP (food assistance) IMPACT clients seeking employment.
• Member Accounting Request 51738
• Notice of Action 35955
• Notice of Action: Spanish 43351
• Parent's Notice 49444
• Personal Representative Authorization 51732
• Reason for Delay of IFSP 51312
• Reciprocal Consent to Release and Share Information 51675
• Record Of Financial Eligibility Budget For Hoosier Healthwise SF 49422
• Record of IMPACT Attendance 44720
  Used by TANF and SNAP (food assistance) IMPACT clients to record attendance or work required when participating in the IMPACT program.
• Report of Job Placement - IMPACT Service Provider 47579
  Used by IMPACT providers and local offices of Family & Children to record job placements.
• Report on Complaint Filed 51735
• Request for Authorization/Meeting Minutes 51839
• Request for Authorization for Transition Meeting/Transition Checklist 51670
• Request for Transportation 47300
  Request for DFR to provide transportation for needed services, like visitation with a child by foster or biological parents, custodians, or caregivers.
• Request to Access Indiana Health Coverage 51731
• Researching the Occupation - Interview Questionnaire 48416
  Used by IMPACT, TANF & SNAP (food assistance) clients to research an occupation.
• Researching the Vocational or Job Skills Training Program 48417
  Used by IMPACT, TANF & SNAP (food assistance) clients to research Vocational or Job Search Training Programs.
• Revocation of Authorization 51736
• Solicitud Para Hoosier Healthwise Para Niños & Mujeres Embarazadas 48974
  Spanish version of the application for health coverage under Hoosier Healthwise for children under age 19 and pregnant women.
• Supplement to Health Program Form - Infant/Toddler 45878
• Transition Meeting Notification 51671
• Written Nutrition Food Service Program for Child Care Centers 46684
• Written Nutrition Food Service Program Infant/Toddler Child Care Centers 46682 

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