Homepage State 53263 Indiana Form in PDF
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The State Form 53263, prominently known as the Indiana Application for SNAP and Cash Assistance, is a crucial document for residents seeking nutritional or financial support in the state of Indiana. Required to be filled out with utmost accuracy, this application ensures that individuals and families in need can apply for the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or aid for refugees. While the form requires comprehensive information, including personal details, household size, income, and expenses, it also emphasizes the importance of honesty in the application process, highlighting the repercussions of falsification. Moreover, it introduces an Expedited Service for SNAP, designed for immediate assistance under critical circumstances, thus ensuring support reaches those in dire need promptly. The guidelines stress the necessity of a signature for application validity, further indicating the legal affirmation of the information provided by the applicants. With sections dedicated to providing details on other household members, the design of the form is inclusive, ensuring that every potential beneficiary is considered. Additionally, it accommodates representatives applying on behalf of others, making it accessible for individuals unable to apply themselves. The application also underscores the legal obligations and rights, including the assignment of child support rights to the Division of Family Resources when applying for TANF and the requirements for work registration in SNAP, thereby aligning with federal and state regulations.

Sample - State 53263 Indiana Form

INDIANA APPLICATION FOR SNAP

AND CASH ASSISTANCE

*DFRAAHE01*

State Form 53263 (R8 / 6-13) / DFR 2512

INSTRUCTIONS: Please fill out your application as completely as you can. It will help if you can answer all of the questions. However, the application will be valid if you provide name(s), address, and signature. To be considered for expedited SNAP (Food Assistance) service you must complete all of Section 8. Please do not forget to sign your application on Page 1 Section 3.

1.If you are completing this application on behalf of someone else and you do not live in their household, please provide your name below and your contact information in Section 7. If you are completing this application on behalf of

someone else and you do live in their household, please provide your information in Section 9:

First Name

MI Last Name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Information for person needing assistance: (additional individuals may be added in Section 9)

Check the Help This Person Needs:

 

 

SNAP (Food Assistance)

 

Cash Assistance (TANF or Refugee)

If Not Applying is checked, completion of the Social Security Number and US Citizen information is optional.

First Name

 

 

 

 

 

MI Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not Applying

Suffix

Date of Birth (mm-dd-yyyy)

 

 

 

Social Security Number

 

 

 

 

 

Gender:

 

 

 

 

 

US Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

F

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

 

 

Single

 

 

Married

 

 

 

 

 

Divorced

Separated

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

Hispanic or Latino?

Yes

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race: (select all that apply)

White

 

 

 

 

 

Black or African American

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian or Alaskan Native

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

Number and Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment/Lot Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

County:

How many people live at this address including you?

State

 

 

Zip Code

Telephone Number:

OFFICIAL USE ONLY

3. Signature and Date Required: Read carefully, then sign & date below.

I understand the following:

INFORMATION THAT I GIVE IS SUBJECT TO VERIFICATION BY FEDERAL, STATE, OR LOCAL OFFICIALS TO DETERMINE IF THE INFORMATION IS FACTUAL. IF ANY INFORMATION IS INCORRECT, SNAP OR OTHER BENEFITS MAY BE DENIED AND THE APPLICANT MAY BE SUBJECT TO CRIMINAL PROSECUTION FOR KNOWINGLY PROVIDING INCORRECT INFORMATION (7 CFR 273.2(b)(1)(i)).

A person fleeing to avoid felony prosecution or jail after a felony conviction or is in violation of probation/parole resulting from a felony conviction is not eligible to receive SNAP and / or Temporary Assistance for Needy Families (TANF).

A person convicted under federal or state law of a felony that includes possession, use, or distribution of a controlled substance is not eligible to receive SNAP and / or TANF.

If applying for Temporary Assistance for Needy Families (TANF), my signature assigns and transfers to the Division of Family Resources all child support rights (accrued, pending, and continuing) which I have against absent parent(s). This assignment is subject to 42 USC SECTION 602(a)(26) as amended.

If applying for SNAP, I am registering all persons required to register for work and perform specific work including cooperation with employment and training activities.

I have received a copy of the "Notice Regarding Rights and Responsibilities" and I understand all information included on this form.

To be considered for Expedited SNAP service, your household must have less than $150 in monthly gross income and have $100 or less in cash; or be a seasonal/migrant farm worker with $100 or less in available cash; or have a combined cash and monthly gross income amount less than the household monthly rent/mortgage and utility expenses.

I certify under penalty of perjury, all information I have given on this application, any attachments and information provided during the eligibility determination process is complete and correct to the best of my knowledge and belief, including the citizenship or immigration status of each applicant.

Signature

Date (mm-dd-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Go to the next page

Page 1 of 5

INDIANA APPLICATION FOR SNAP AND CASH ASSISTANCE

State Form 53263 (R8 / 6-13) / DFR 2512

*DFRAAHE02*

4.Mailing Address (if different than home address):

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Alternate Telephone:

Work Telephone:

6. E-mail address:

7. If you are completing this application on behalf of someone else, please provide your contact information below:

Street Address

City

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number:

Do you live with the person(s) needing assistance?

Yes

If no, what is your relationship to the person(s) needing assistance?

Zip Code

No

NOTE: If you are a representative for the person(s) needing assistance, the applicant must complete and sign the enclosed Authorized Representative form.

8. Expedited Service for SNAP (Food Assistance):

If you are not applying for SNAP, skip to section 9. If you are applying for SNAP and want to be considered for Expedited SNAP service, please answer all questions in this section. Write all amounts even if 0.

Enter how much total gross earned income (before taxes/deductions) your household will receive this month:

Enter how much total unearned income or other money your household will receive this month: (Unearned income includes: Social Security, child support, unemployment, etc.)

Enter your total household money in cash, checking accounts, savings accounts, other:

Enter the amount you are charged each month for your rent or mortgage:

$

$

$

$

Do you pay to heat or cool your home?

 

Yes

 

No

 

 

If no, do you pay for any other utilities (electric, water, sewer, etc)?

 

Yes

 

No

 

 

 

 

 

 

 

Is anyone in your household a migrant worker or seasonal farm worker?

 

Yes

 

No

 

 

If yes, will you receive income from your former employer after today?

 

Yes

 

No

 

 

Will you receive more than $25 income from your new employer within 10 days?

 

Yes

 

No

 

 

 

 

 

 

 

Has everyone in your household (including you) been approved to receive SNAP benefits this month?

 

Yes

 

No

 

 

 

 

 

 

 

Go to the next page

Page 2 of 5

INDIANA APPLICATION FOR SNAP

AND CASH ASSISTANCE

State Form 53263 (R8 / 6-13) / DFR 2512

*DFRAAHE03*

9.Provide the following information for all other persons who live at the home address in Section 2:

Person listed in Section 2 does not need to be listed again.

If Not Applying is checked, completion of the Social Security Number and US Citizen information is optional.

Check the Help This Person Needs:

 

SNAP (Food Assistance)

 

 

Cash Assistance (TANF or Refugee)

 

Not Applying

First Name

 

 

 

 

 

MI

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm-dd-yyyy)

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

 

 

 

 

 

 

 

 

 

 

US Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

F

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

 

 

 

 

Single

 

 

 

 

Married

 

 

 

 

 

Divorced

 

 

 

 

 

 

Separated

 

 

 

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

Hispanic or Latino?

 

 

 

 

Yes

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race: (select all that apply)

 

 

White

 

 

 

 

 

Black or African American

 

 

 

 

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian or Alaskan Native

 

 

 

 

 

 

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to person needing assistance listed in Section 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check the Help This Person Needs:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNAP (Food Assistance)

 

 

 

Cash Assistance (TANF or Refugee)

 

 

 

Not Applying

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm-dd-yyyy)

 

 

 

Social Security Number

 

 

 

 

 

Gender:

 

 

 

 

 

 

 

US Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

 

 

 

 

Single

 

 

 

Married

 

 

 

 

 

Divorced

 

 

 

Separated

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

Hispanic or Latino?

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White

 

 

 

 

 

Black or African American

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race: (select all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian or Alaskan Native

 

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to person needing assistance listed in Section 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Go to the next page

Page 3 of 5

INDIANA APPLICATION FOR SNAP

AND CASH ASSISTANCE

State Form 53263 (R8 / 6-13) / DFR 2512

*DFRAAHE04*

Check the Help This Person Needs:

 

SNAP (Food Assistance)

 

 

Cash Assistance (TANF or Refugee)

 

Not Applying

First Name

 

 

 

 

 

MI

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm-dd-yyyy)

 

 

 

Social Security Number

 

 

 

 

 

Gender:

 

 

 

 

 

 

 

US Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

 

 

 

 

Single

 

 

 

Married

 

 

 

 

 

Divorced

 

 

 

Separated

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

Hispanic or Latino?

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race: (select all that apply)

 

 

White

 

 

 

 

 

Black or African American

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian or Alaskan Native

 

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to person needing assistance listed in Section 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check the Help This Person Needs:

 

 

SNAP (Food Assistance)

 

 

Cash Assistance (TANF or Refugee)

 

Not Applying

First Name

 

 

 

 

 

MI

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm-dd-yyyy)

 

 

 

Social Security Number

 

 

 

 

 

Gender:

 

 

 

 

 

 

 

US Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

 

 

 

 

Single

 

 

 

Married

 

 

 

 

 

Divorced

 

 

 

 

Separated

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

Hispanic or Latino?

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White

 

 

 

 

 

Black or African American

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race: (select all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian or Alaskan Native

 

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to person needing assistance listed in Section 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Go to the next page

Page 4 of 5

INDIANA APPLICATION FOR SNAP

AND CASH ASSISTANCE

State Form 53263 (R8 / 6-13) / DFR 2512

*DFRAAHE05*

Check the Help This Person Needs:

 

 

SNAP (Food Assistance)

 

 

Cash Assistance (TANF or Refugee)

 

Not Applying

First Name

 

 

 

 

 

MI

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm-dd-yyyy)

 

 

 

Social Security Number

 

 

 

 

 

Gender:

 

 

 

 

 

 

 

US Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

 

 

 

 

Single

 

 

 

Married

 

 

 

 

 

Divorced

 

 

 

 

Separated

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

Hispanic or Latino?

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race: (select all that apply)

 

 

White

 

 

 

 

 

Black or African American

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian or Alaskan Native

 

 

Native Hawaiian or Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to person needing assistance listed in Section 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If more than six (6) people live at your address, please provide the information starting on page 6.

10.

What is your preference for your application interview appointment?

By telephone

At an office

 

Please indicate if you need the following interpreter services for your application interview appointment:

 

 

 

 

 

Language interpreter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sign Language interpreter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Do you want to receive automated calls from our agency?

 

 

 

 

 

Yes

No

 

 

(Examples of calls you may receive are appointment reminders or due dates for requested documents.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Do you want to register to vote?

 

 

Yes

 

 

No

Your answer will not affect your eligibility for benefits.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 5 of 5

Form Overview

Fact Description
Form Identifier State Form 53263 (R8 / 6-13) / DFR 2512
Purpose Application for SNAP and Cash Assistance in Indiana
Expedited Service Criteria To be considered for Expedited SNAP service, a household must have less than $150 in monthly gross income and $100 or less in cash, or fit other specific criteria.
Eligibility Requirements Applicants are subject to verification by federal, state, or local officials, and certain convictions may disqualify them from SNAP or TANF benefits.
Governing Laws Various federal regulations and statutes including 7 CFR 273.2(b)(1)(i) for SNAP and 42 USC SECTION 602(a)(26) for TANF.

Guide to Filling Out State 53263 Indiana

Filling out the State 53263 Indiana form is your first step towards applying for SNAP (Supplemental Nutrition Assistance Program) and Cash Assistance in Indiana. This form serves as a comprehensive document that the Division of Family Resources will use to assess your eligibility for the assistance you are requesting. With precision and diligence, completing this form correctly will ensure a smoother process in obtaining the support you and your household may need. Follow these steps to ensure your form is filled out comprehensively:

  1. Start by reading the instructions carefully on the top of the form to understand the requirements.
  2. In Section 1, if you are completing the application for someone else, fill in your contact information accordingly. If you live in the same household, your details will go in Section 9.
  3. For Section 2, provide comprehensive information for the person needing assistance, including their name, date of birth, social security number, and household size. Indicate whether they need SNAP, Cash Assistance, or both. If they are not applying, you may skip the social security number and citizenship status fields.
  4. In Section 3, it's essential that you read and understand the declarations. Once done, sign and date the form to validate the information provided.
  5. If there's a different mailing address, specify this in Section 4.
  6. Update your contact details, including an alternate telephone number and email address in Section 5.
  7. If completing this on behalf of someone else, add your address and telephone number in Section 7, and specify your relationship to the applicant.
  8. Section 8 is crucial for expedited SNAP service applicants. Fill out all the fields here if you wish to be considered for expedited services.
  9. For households with additional members, provide their details in Section 9, ensuring you cover all necessary information such as name, date of birth, social security number, and their relationship to the primary applicant.
  10. Select your interview preference in Section 10, and if you require any interpreter services, specify your needs.
  11. Indicate whether you wish to receive automated calls and if you want to register to vote in Section 11 and Section 12, respectively.
  12. After filling out the information through Page 4, review your entries for accuracy. This ensures the information provided is correct to the best of your knowledge, reducing potential delays in processing.
  13. Finally, submit the form to the Division of Family Resources through the instructed channels, either in person or online, if applicable.

By following these detailed instructions, you are taking an important step towards receiving the assistance you need. Remember, accuracy and completeness in your application can expedite the review process, bringing you closer to the benefits you seek.

Frequently Asked Questions

What is the State Form 53263 used for in Indiana?

State Form 53263 is an application form used in Indiana for individuals or families seeking SNAP (Supplemental Nutrition Assistance Program) and Cash Assistance. This includes benefits under Temporary Assistance for Needy Families (TANF) or for refugees.

Who needs to complete State Form 53263?

Any Indiana resident who requires SNAP or Cash Assistance benefits should complete State Form 53263. If you are applying on behalf of someone else who lives in your household, you should include your information in Section 9 of the form.

What information is mandatory for the application to be valid?

For the application to be considered valid, at a minimum, the applicant must provide name(s), address, and signature. Completing the form as thoroughly as possible, however, can help expedite the processing.

Can someone else fill out the form on behalf of an applicant?

Yes, if you are completing the application on behalf of someone else, you must provide your contact information in Section 7. If you live with the applicant, your information should be included in Section 9 instead.

What is required to be considered for Expedited SNAP service?

To be eligible for Expedited SNAP service, applicants must complete all of Section 8. Qualification for expedited service depends on the household’s monthly gross income, cash on hand, and monthly rent/mortgage and utility expenses.

How does one assign rights for child support when applying for TANF?

Applying for Temporary Assistance for Needy Families (TANF) involves assigning and transferring all child support rights to the Division of Family Resources. This includes child support that is accrued, pending, and continuing against absent parent(s).

Are there any eligibility restrictions based on legal status?

Yes, individuals fleeing to avoid felony prosecution, jail after a felony conviction, or in violation of probation/parole from a felony conviction are not eligible for SNAP and/or TANF. Additionally, those convicted of a felony involving drugs may also be ineligible.

What happens after submitting the application?

After submission, the application will be reviewed by the Division of Family Resources. Applicants may be contacted for an interview or to provide further documentation. An accurate and complete application can expedite this process.

Is there a section to indicate how the interview should be conducted?

Yes, in Section 10 of the application, applicants can indicate their preference for the interview appointment—whether by telephone or in-person at an office. Applicants can also request interpreter services for the interview if needed.

Common mistakes

When completing the State 53263 Indiana form for SNAP and Cash Assistance, it is crucial to avoid common errors to ensure a smooth process. Here are ten frequent mistakes that applicants should be cautious of:

  1. Not signing the application on Page 1 Section 3. This is a mandatory step for the application to be processed.
  2. Skipping Section 8 when applying for expedited SNAP service. This section is critical for expedited processing.
  3. Failing to provide complete and accurate personal information for every individual in the household who needs assistance, including full name, date of birth, and Social Security numbers if not opting out.
  4. Overlooking the need to indicate the type of assistance needed for each household member listed in Section 9.
  5. Entering incorrect or incomplete income information in Section 8 for both earned and unearned income, which can affect eligibility determinations.
  6. Forgetting to indicate utility payments or rent/mortgage expenses in Section 8, which are necessary to evaluate for expedited SNAP eligibility.
  7. Omitting contact information in Section 7 when completing the application on behalf of someone else, which is necessary for communication purposes.
  8. Not checking the appropriate boxes regarding citizenship, which can lead to issues in verifying eligibility for benefits.
  9. Misunderstanding the requirement to assign child support rights to the Division of Family Resources when applying for TANF, as outlined on Page 1.
  10. Ignoring the optional sections like requesting an interpreter for the application interview appointment, which could be crucial for non-English speakers or the hearing impaired.

Avoiding these mistakes can significantly enhance the accuracy of the application and expedite the process of receiving assistance. It's also important to read the instructions carefully and provide as much detailed information as possible about every household member needing assistance.

Furthermore, it's beneficial to review the application for completeness before submission. Taking these steps seriously ensures that the application process for SNAP and Cash Assistance through State Form 53263 in Indiana goes as smoothly as possible.

Documents used along the form

When applying for SNAP and Cash Assistance in Indiana using the State Form 53263, applicants often need to provide additional documentation to support their application and verify the information they’ve submitted. Understanding what these forms and documents are can streamline the application process and help ensure that it is completed accurately and thoroughly.

  • Proof of Identity: A legal document that verifies the identity of the applicant, such as a driver's license or state ID card. This is necessary to confirm that the applicant is who they claim to be.
  • Income Verification Documents: These can include recent pay stubs, an employer statement, or tax returns that confirm the income details provided in the application. It helps in determining eligibility based on income guidelines.
  • Expense Documentation: Bills or statements for rent, mortgage, utilities, or medical expenses that applicants may have. Providing these documents helps in assessing the amount of assistance an individual or family may qualify for.
  • Bank Statements: Recent bank statements can be requested to verify the cash assets of an applicant. This is to ensure that applicants meet the financial eligibility criteria of the program.
  • Proof of Residence: A utility bill, lease agreement, or a similar document that confirms the applicant’s current living situation and address. This is critical for verifying that the applicant resides in Indiana.

Each of these documents plays a critical role in the eligibility and verification process for SNAP and Cash Assistance in Indiana. Applicants should ensure all relevant forms and documents are included with their application to avoid delays. Proper documentation aids in a smooth processing experience, ultimately assisting individuals and families in receiving the assistance they need in a timely manner.

Similar forms

The State 53263 Indiana form is similar to other government assistance application forms in various aspects, particularly regarding the structure and required information. These forms often ask for personal details, household information, and financial status to determine eligibility for benefits. Below are examples of documents that bear resemblance to the Indiana Application for SNAP and Cash Assistance form and explanations on how they are alike.

Form SSA-8000-BK: The application for Supplemental Security Income (SSI) through the Social Security Administration, Form SSA-8000-BK, shares similarities with the Indiana form. Both documents require applicants to provide detailed personal information, including name, address, social security number, income and resources, and household composition. The forms are designed to collect comprehensive data that aids in assessing eligibility for aid. Furthermore, both applications have sections where applicants must acknowledge understanding their rights and responsibilities pertaining to the application process and possible penalties for providing false information.

Form I-912: The Request for Fee Waiver, Form I-912, used by U.S. Citizenship and Immigration Services, is another document that parallels the State 53263 Indiana form in certain respects. Form I-912 requires detailed personal and financial information to determine if an applicant qualifies for a fee waiver when applying for immigration benefits. Like the Indiana SNAP and Cash Assistance application, this form emphasizes the need for accurate and complete responses, underlining the consequences of misinformation. Both forms serve as critical tools for access to essential services or benefits, contingent on the thoroughness and accuracy of the provided details.

Form 1040: The U.S. Individual Income Tax Return form, though primarily for tax purposes, has sections that mirror the structure of the Indiana assistance application. For instance, both forms inquire about household income, dependents, and personal identification details. While Form 1040 calculates tax liability or refund, it requires comprehensive income data, similar to how the Indiana form assesses eligibility for SNAP and Cash Assistance based on income and household size. This comparison highlights how government forms, regardless of their primary function, share a common thread in collecting personal and financial information to make determinations about benefits or obligations.

Dos and Don'ts

When filling out the State Form 53263 for SNAP and Cash Assistance in Indiana, there are several do's and don'ts that are essential to ensure the process is smooth and your application is considered without unnecessary delay. Following these guidelines carefully can assist in avoiding common pitfalls that might hinder your application's success.

Do:
  1. Read the instructions carefully before you start to fill out the application to make sure you understand what information is required.

  2. Provide your complete and correct information including name, address, and signature, as these are mandatory for the application to be processed.

  3. Answer all questions in Section 8 if you wish to be considered for Expedited SNAP service, as this can shorten the processing time for eligible applicants.

  4. Sign and date the application on Page 1, Section 3 to certify that the information you have provided is accurate to the best of your knowledge.

  5. If you are completing the application on behalf of someone else, be sure to provide your contact information in the designated section based on whether you live in the same household as the applicant.

Don't:
  1. Leave questions unanswered unless specified that they are optional or not applicable to your situation. Incomplete information may delay processing.

  2. Avoid providing false information. Misleading or incorrect information can lead to denial of benefits and potential criminal prosecution.

  3. Forget to check the type of assistance needed for each person included in the application. Clearly indicating whether SNAP or Cash Assistance is required helps ensure the right support is given.

  4. Neglect to request an interpreter service if needed for your application interview appointment to ensure effective communication.

By adhering to these guidelines, you can help ensure that your application for SNAP and Cash Assistance is accurately completed and processed in a timely manner.

Misconceptions

Understanding the State Form 53263 in Indiana can occasionally lead to misconceptions. Addressing these misunderstandings ensures that applicants have the correct information before they apply for benefits.

  • Misconception 1: Completing the whole application is mandatory for submission. It's not required to answer every question for the application to be considered valid. Providing name(s), address, and a signature is sufficient for submission, but completing the application as fully as possible can expedite the process.

  • Misconception 2: Expedited SNAP service is available to all applicants. Expedited service is targeted towards households with extremely low income and resources. Specific criteria, detailed in Section 8, must be met to qualify for this service.

  • Misconception 3: You cannot apply on behalf of someone else. You can apply for someone else if you provide your information in the appropriate section depending on whether you live with the applicant or not. This is clarified in the application instructions.

  • Misconception 4: Signing the form doesn't have legal implications. The signature section underscores that providing false information can lead to criminal prosecution. Signing the form asserts that information provided is true to the best of the applicant's knowledge.

  • Misconception 5: The form is only for applying for SNAP. The form is also designed for applying for Cash Assistance, like TANF or Refugee assistance, alongside SNAP.

  • Misconception 6: Felony convictions have no impact on eligibility. Individuals fleeing felony prosecution or violating probation/parole from a felony, as well as those convicted of certain drug-related felonies, are ineligible for benefits as stated in the form.

  • Misconception 7: Social Security Numbers are always required. If the person is "Not Applying" for assistance, filling in their Social Security Number and US citizenship information is optional.

  • Misconception 8: Only immediate family members count as part of your household. The application process considers all individuals living at the address as part of the household, and their information may affect the benefits.

  • Misconception 9: Information about child support is irrelevant when applying for TANF. When applying for TANF, your signature gives the Division of Family Resources the right to collect child support from absent parents, indicating the relevance of this information.

Addressing these misconceptions helps ensure that individuals have all the necessary information to correctly complete the State Form 53263 application process in Indiana.

Key takeaways

When filling out the State Form 53263 Indiana for SNAP and Cash Assistance applications, it's important to have a clear understanding of the process to ensure accurate and complete submissions. Here are five key takeaways:

  • Application Completeness: Although the application will be considered valid with basic information like name(s), address, and signature, completing all sections thoroughly can expedite processing. Section 8 must be fully completed for those considering expedited SNAP service.
  • Applicant Representation: If someone is filling out the form on behalf of the applicant without living in the same household, their contact information should be provided in Section 7. However, if they reside in the same household, their details go in Section 9, underscoring the form’s flexibility in representation.
  • Expedited SNAP Service Eligibility: The criteria for expedited SNAP service consideration include having less than $150 in monthly gross income and $100 or less in cash, being a migrant or seasonal farm worker with $100 or less in available cash, or having monthly expenses exceeding your income.
  • Signature and Verification: The applicant’s signature is required, attesting to the veracity of information provided. It’s a declaration that the information is complete and correct to the best of their knowledge, and false information could lead to denial of benefits or criminal prosecution.
  • Additional Information for Household Members: Section 9 is dedicated to adding more individuals living at the same address. It emphasizes inclusivity, allowing for the needs of each household member to be addressed individually, without having to complete separate applications.

Understanding these key aspects of the State Form 53263 can significantly impact the successful submission of an application for SNAP and Cash Assistance in Indiana. Applicants and their representatives are encouraged to provide detailed and accurate information, ensure all relevant sections are completed, and understand the importance of their signature confirming the truthfulness of their application.

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