Forms
- DFR: Authorization Representative Form
- DFR: Authorization for Disclosure of Personal and Health Information Form
All Counties: Fax to 1-800-403-0864 or deliver or mail to your local county office.
If you don't see the form you are searching for in the sections below, click here to 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 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)
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 Responsibilities, Sanctions, and Rights Voluntary Clients 49049
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465
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.
Bureau of Child Care Forms
Breast Milk Procedure 49954Child 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 49952Notice of Action 1859
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
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
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".
- Apply for or check the status of my Medicaid (health coverage), SNAP (food assistance) or TANF (cash assistance) benefits.
- Find a quality child care provider in my local area.
- Learn about home and community-based supports for the elderly.
- Learn about job assistance for people with disabilities.
- Seek help for a mental health issue or a drug, alcohol or gambling addiction.
