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pdfINDIANA APPLICATION FOR SNAP
AND CASH ASSISTANCE
*DFRAAIE01*
State Form 53263 (R10 / 3-16) / 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)
Not Applying
If Not Applying is checked, completion of the Social Security Number and US Citizen information is optional.
First Name
MI
Date of Birth (mm-dd-yyyy)
Last Name
Suffix
Gender:
Social Security Number
US Citizen?
Male
Marital Status:
Ethnicity:
Single
Married
Hispanic or Latino?
Race: (select all that apply)
Divorced
Yes
White
Separated
Black or African American
Asian
Multiracial
Native Hawaiian or Pacific Islander
Apartment/Lot Number
State
County:
No
Widowed
Number and Street
City
Yes
No
American Indian or Alaskan Native
Home Address:
Female
ZIP Code
Telephone Number:
OFFICIAL USE ONLY
How many people live at this address including you?
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 REDUCED OR DENIED AND THE APPLICANT MAY BE SUBJECT TO CRIMINAL
PROSECUTION OR DISQUALIFIED FROM ANY PROGRAM 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 which occurred after August 22, 1996, 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
*DFRAAIE02*
State Form 53263 (R10 / 3-16) / DFR 2512
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
ZIP Code
Telephone number:
Do you live with the person(s) needing assistance?
Yes
No
If no, what is your relationship to the person(s) needing assistance?
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
Yes
No
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
Yes
No
If no, do you pay for any other utilities (electric, water, sewer, etc)?
Is anyone in your household a migrant worker or seasonal farm worker?
Has everyone in your household (including you) been approved to receive SNAP benefits this month?
Go to the next page
Page 2 of 5
INDIANA APPLICATION FOR SNAP
AND CASH ASSISTANCE
*DFRAAIE03*
State Form 53263 (R10 / 3-16) / DFR 2512
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)
First Name
MI
Date of Birth (mm-dd-yyyy)
Cash Assistance (TANF or Refugee)
Suffix
Last Name
Gender:
Social Security Number
US Citizen?
Male
Marital Status:
Ethnicity:
Single
Married
Race: (select all that apply)
Divorced
Yes
Hispanic or Latino?
White
Not Applying
Separated
Female
Yes
No
Widowed
No
Black or African American
American Indian or Alaskan Native
Asian
Multiracial
Native Hawaiian or Pacific Islander
Relationship to person needing assistance listed in Section 2:
Check the Help This Person Needs:
SNAP (Food Assistance)
First Name
MI
Date of Birth (mm-dd-yyyy)
Cash Assistance (TANF or Refugee)
Suffix
Last Name
Gender:
Social Security Number
US Citizen?
Male
Marital Status:
Ethnicity:
Single
Married
Hispanic or Latino?
Race: (select all that apply)
White
Divorced
Yes
Not Applying
Separated
Female
Yes
No
Widowed
No
Black or African American
American Indian or Alaskan Native
Asian
Multiracial
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
*DFRAAIE04*
State Form 53263 (R10 / 3-16) / DFR 2512
Check the Help This Person Needs:
SNAP (Food Assistance)
First Name
MI
Date of Birth (mm-dd-yyyy)
Cash Assistance (TANF or Refugee)
Suffix
Last Name
Gender:
Social Security Number
US Citizen?
Male
Marital Status:
Ethnicity:
Single
Married
Race: (select all that apply)
Divorced
Yes
Hispanic or Latino?
White
Not Applying
Separated
Female
Yes
No
Widowed
No
Black or African American
American Indian or Alaskan Native
Asian
Multiracial
Native Hawaiian or Pacific Islander
Relationship to person needing assistance listed in Section 2:
Check the Help This Person Needs:
SNAP (Food Assistance)
First Name
MI
Date of Birth (mm-dd-yyyy)
Cash Assistance (TANF or Refugee)
Suffix
Last Name
Gender:
Social Security Number
US Citizen?
Male
Marital Status:
Ethnicity:
Single
Married
Hispanic or Latino?
Race: (select all that apply)
White
Divorced
Yes
Not Applying
Separated
Female
Yes
No
Widowed
No
Black or African American
American Indian or Alaskan Native
Asian
Multiracial
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
*DFRAAIE05*
State Form 53263 (R10 / 3-16) / DFR 2512
Check the Help This Person Needs:
SNAP (Food Assistance)
First Name
MI
Date of Birth (mm-dd-yyyy)
Cash Assistance (TANF or Refugee)
Suffix
Last Name
Gender:
Social Security Number
US Citizen?
Male
Marital Status:
Ethnicity:
Single
Married
Hispanic or Latino?
Race: (select all that apply)
Divorced
Yes
White
Not Applying
Separated
Female
Yes
No
Widowed
No
Black or African American
American Indian or Alaskan Native
Asian
Multiracial
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
Yes
No
11. Do you want to receive automated calls from our agency?
(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
NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
*DFRNRAE01*
State Form 54105 (R13 / 3-18) / DFR 0009C
Client Name:
Case Number:
CASH ASSISTANCE – Temporary Assistance for Needy Families (TANF); Refugee Cash Assistance (RCA);
SNAP (Food Assistance)
Please read this form about the rights and responsibilities of the programs you have chosen. When we refer to “you”, we mean all persons
applying for and receiving benefits in your household.
SECTION 1
THIS SECTION APPLIES TO SNAP AND CASH ASSISTANCE.
Additional requirements for the specific programs are in the following sections.
1.
You have the right to apply for benefits at any time during normal office hours. The date you turn in your application determines the date your
benefits begin if you are eligible. Don’t delay in filing your application.
2.
You may appoint someone to apply for benefits on your behalf.
3.
A decision must be made on your application within the following time frames: thirty (30) days for SNAP if you are not entitled to expedited
service; and sixty (60) days for Cash Assistance.
4.
Privacy Statement:
•
We are authorized to collect your information (on the application and other supporting documentation) under state and federal laws and
regulations, including but not limited to IC 4-22-2, 45 CFR 206.10, and 7 CFR Part 271.
•
All personal information you provide is kept confidential and will only be used to determine your eligibility for benefits, and to communicate
with you or your authorized representative. Your personal information is protected by both state and federal law. The Division of Family
Resources takes the privacy of your information seriously and employs numerous privacy and security controls to safeguard your
information.
•
If you believe that we have violated the privacy of your information, please contact the Division of Family Services, either by visiting your
local office or calling 1-800-403-0864. You may also contact the Family & Social Services Administration Privacy Officer by phone (1-877690-0010) or email ([email protected]).
•
The information you provide will be entered into our eligibility computer system. You have the right to review that information and to
request corrections or amendments to that information, and may do so by visiting your local Division of Family Resources office or calling
1-800-403-0864 (please note that requested corrections or amendments are subject to verification by our staff as required by state and
federal regulations).
5.
You will need to answer all questions that are required to determine eligibility for the programs you have chosen.
6.
Eligibility for benefits is determined without any regard to race, color, creed, sex, age, handicap, national origin, or political belief. Information
is requested about your racial-ethnic heritage to comply with the Federal Civil Rights Law and the Food and Nutrition Act. However, you do
not have to provide this information as it is strictly voluntary. If you choose not to give us this information, we will indicate a race/ethnicity
classification for you for data collection purposes. This will not affect your eligibility or level of benefits. The reason for collecting this information
is to assure that program benefits are distributed without regard to race, color or national origin.
7.
A Social Security number (SSN) must be given for each applicant who can legally have a number. If you don’t have an SSN you must apply for
one. Your SSN will be used to check the records of other State and Federal agencies such as the Social Security Administration, Bureau of Motor
Vehicles, Internal Revenue Service, Department of Workforce Development, and other states’ public assistance records. Information available
through the Income Eligibility Verification System (IEVS) will be requested, used, and may be verified through collateral contacts when
discrepancies are found by the State, and that such information may affect the household’s eligibility and level of benefits. We may ask for the
Social Security numbers of family members who are not applying; however, you do not have to provide these numbers as a condition of eligibility.
Determination of eligibility will not be delayed, denied, or discontinued due to waiting on a Social Security number to be issued. If discrepancies
are found, this may affect the household's eligibility and level of benefits.
8.
If you are an immigrant, you must provide the document showing your immigration status. A person who does not provide immigration
documents or has no documentation cannot receive SNAP or Cash Assistance. The immigration status of lawful immigrants who are applying
for or receiving benefits is subject to verification through the Systematic Alien Verification System (SAVE) administered by the U.S. Citizenship
and Immigration Services (USCIS). Information received from USCIS may affect the household's eligibility and level of benefits.
9.
Undocumented immigrants who are not applying for assistance will not be reported to the United States Citizenship and Immigration Service.
10.
In order to remain eligible for SNAP and Cash Assistance, you may be referred to the employment and training program. You will be required
to participate in the employment and training program and do specific activities, unless you meet certain exemption criteria. TANF work ready
applicants are required to complete Applicant Job Search (AJS) as a condition of the eligibility process. Failure to complete AJS without good
cause may be grounds for denying the TANF application.
11.
If you voluntarily quit a job, or voluntarily reduce employment hours without good reason or if you are terminated from a job for disciplinary
reasons, it may affect your eligibility and the amount of benefits you receive.
12.
You will need to verify certain information you provide, based on the requirements of the programs you have chosen. If you have tried to get
the verification(s), but are unable to do so, you can sign a release of information and the caseworker will get the information. Any release of
information form that you sign must have the name of the person, agency, or organization that the caseworker will be contacting. This release
is to be signed only if confidential information needs to be shared in order to obtain the verification, such as from a medical facility or financial
institution.
Page 1 of 5
DFRNRAE01
NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
*DFRNRAE02*
State Form 54105 (R13 / 3-18) / DFR 0009C
SECTION 1 (continued)
THIS SECTION APPLIES TO SNAP AND CASH ASSISTANCE.
13. Certain persons must be included in the application and/or have their income, resources, needs and/or expenses counted in determining
eligibility for benefits. For this reason you must report everyone who lives with you. In certain instances, a limited amount of your personal
information may be disclosed to another household member or their authorized representative in order to complete the required eligibility
processes.
14.
You are required to report changes in your circumstances to the Division of Family Resources. The changes that you must report include
your new address if you move, increases or decreases in your household’s income, resources, or any change in your family circumstances
that may affect your eligibility for benefits. You must report changes within ten (10) days of the date on which you are aware of the change.
SNAP assistance groups must only report when their gross monthly income exceeds the gross monthly income limit for their assistance
group size. The monthly income limit is included in the notice of eligibility. This change must be reported by the tenth (10th) day of the next
month following the change to be considered timely. You will be given a form describing your reporting requirements.
15.
You are required to provide complete and correct information to the best of your knowledge. A person who receives benefits by intentionally
giving false information or by failing to report information may be criminally prosecuted under State and Federal law.
16. You have the right to receive a written notice about any action taken on your application or on the benefits you receive.
17. You may request a fair hearing in writing if you disagree with any action taken on your case, including the late processing of your application.
Your case may be presented at the hearing by any person you choose. (Note: SNAP recipients may make their request for a SNAP hearing
verbally.)
18. Any individual who is fleeing to avoid prosecution or confinement after felony conviction, or is in violation of probation or parole
resulting from a felony conviction will be ineligible to receive SNAP and TANF benefits. Information in your case file may be
released to law enforcement officials to allow them to arrest persons fleeing to avoid the law.
19. Any individual who has been convicted under federal or state law of a felony, and this felony includes the possession, use, or
distribution of a controlled substance will be ineligible to receive benefits. Ineligibility under this provision is limited to
convictions based on behavior which occurred after August 22, 1996.
20. This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or
political beliefs.
The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age,
political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard
of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English,
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter
all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or
letter to USDA by:
1.
mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
2.
fax: (202) 690-7442; or
3.
email: [email protected]
For any other information dealing with the Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the
USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a
listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and
Human Services (HHS), write: HHS Director, Office of Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201
or call (202) 619-0403 (voice) or (800) 537-7697 TTY).
This institution is an equal opportunity provider.
SECTION 2
THIS SECTION APPLIES ONLY TO SNAP.
If you are not applying for SNAP benefits go on to Section 3.
1.
If your household has little or no income, or includes a migrant or seasonal farm worker, your application for SNAP benefits may receive
special expedited processing. This means that you may receive SNAP benefits within seven (7) days from the date the application is filed.
To qualify for expedited processing, you must complete all the expedited service questions on the Application for Assistance. If you do not
qualify for expedited processing, you may request a conference. The conference will be scheduled within two (2) days and will not replace
or delay the request for a fair hearing.
Page 2 of 5
DFRNRAE02
NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
*DFRNRAE03*
State Form 54105 (R13 / 3-18) / DFR 0009C
SECTION 2 (continued)
2.
THIS SECTION APPLIES ONLY TO SNAP.
To be eligible for SNAP benefits, persons age sixteen (16) through fifty-nine (59) must register for work and do specific activities. These
activities include work registration, accepting and keeping suitable employment, and cooperating with IMPACT. Individuals who fail to
cooperate with these rules without a good reason can be disqualified from receiving SNAP benefits until they cooperate or for at least two
(2) months for the first violation, six (6) months for the second violation, and thirty-six (36) months for the third violation. Some persons can
be exempt from these requirements. Ask a caseworker about exemptions.
3.
If you are overpaid SNAP benefits and an overpayment claim is done against your household, the information on your application and all
Social Security Numbers (SSNs) may be referred to federal and state agencies and private collection agencies for collection purposes.
4.
Every person who receives SNAP benefits must follow these rules:
⇒
⇒
⇒
⇒
⇒
DO NOT give false information to get or continue to get SNAP benefits.
DO NOT trade or sell SNAP benefits or Hoosier Works cards.
DO NOT alter documents to get more SNAP benefits than you are entitled to receive.
DO NOT use SNAP benefits to buy ineligible items, such as alcoholic drinks and tobacco
DO NOT use someone else’s SNAP benefits or Hoosier Works card for your personal gain.
If you break the above rules on purpose you can be barred from the SNAP for twelve (12) months if it is your first violation, twenty-four (24)
months for a second violation and permanently for a third violation.
Any person who purchases illegal drugs with SNAP benefits will be barred from the program twenty-four (24) months for the first
violation, and permanently for the second violation.
A person will be disqualified for ten (10) years if the Family & Social Services Administration or a State or Federal court determines
they made false statements or gave false information about their identity or place of residence and received duplicate SNAP
benefits.
5.
Trafficking is defined as follows:
•
The buying, selling, stealing, or otherwise effecting an exchange of SNAP benefits issued or accessed via Hoosier Works EBT cards,
Hoosier Works EBT card numbers and personal identification numbers (PINs), or by manual voucher and signature, for cash or
consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone;
• The exchange of firearms, ammunition, explosives, or controlled substances, for SNAP benefits as defined in Section 802 of Title 21,
U.S.C.
• Purchasing a product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining cash by discarding
the product and returning the container for the deposit amount, intentionally reselling the product purchased with SNAP benefits in
exchange for cash or consideration other than eligible food;
• Purchasing a product with SNAP benefits with the intent of obtaining cash or consideration other than eligible food by reselling the
product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for cash or consideration other
than eligible food;
• Intentionally purchasing products originally purchased with SNAP benefits in exchange for cash or consideration other than eligible
food.
Any person convicted of trafficking SNAP benefits of five hundred ($500) dollars or more will be permanently barred from SNAP.
Any person convicted of the exchange of firearms, ammunition, explosives for SNAP benefits, regardless of dollar amount, will
be permanently barred from SNAP.
Violators may also be fined up to two hundred fifty thousand ($250,000) dollars, put in jail for up to twenty (20) years, or both, and
may be subject to prosecution under other Federal or State laws. In addition to such penalties, any person convicted of a felony
or misdemeanor violation under this section may be suspended by the court from participation in SNAP for an additional period
of up to eighteen (18) months consecutive to that period of suspension mandated by the Food and Nutrition Act.
6.
If you are not part of an assistance group with a child under age eighteen (18), are able-bodied, and between the ages of eighteen (18) and
forty-nine (49), you may receive SNAP benefits no longer than three (3) months unless you:
•
Work at least twenty (20) hours per week on average each month; or
•
Participate in a Job Program approved by the Family and Social Services Administration at least twenty (20) hours per week or meet one
of the exemptions, or
•
Participate in a Community Work Experience Program (CWEP) activity.
If you have lost eligibility after receiving SNAP benefits for three (3) months, you may regain eligibility by:
•
Working at least eighty (80) hours in a thirty (30) day period, or,
•
Participating at least eighty (80) hours in a thirty (30) day period in an approved Job Program, or
•
Meeting one of the exemptions
7.
To receive a deduction for the following expenses, you must report and provide proof to a caseworker of:
Child Care Expense
Rent or Mortgage Payments
Medical Expenses
Utility or other shelter costs
Child support paid to a non-household member
8.
Failure to report or verify any of the above listed expenses will be accepted as a statement by your household that you do not want to receive a
deduction for the unreported expense.
9.
When a resident of an institution is jointly applying for SNAP and SSI prior to leaving the institution, the filing date of the application for SNAP
benefits that the State agency must record is the date of release of the applicant from the institution.
Page 3 of 5
DFRNRAE03
NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
*DFRNRAE04*
State Form 54105 (R13 / 3-18) / DFR 0009C
SECTION 3
1.
THIS SECTION APPLIES ONLY TO CASH ASSISTANCE.
Support rights (accrued, pending, and continuing) must be assigned to the State as a condition of eligibility for TANF. The assignment is
subject to 42 U.S.C. Section 608 (a)(3) as amended. The assignment of support rights constitutes a financial obligation that is owed to the
State by the payor(s). You must agree to cooperate with support enforcement, which could include: identifying and locating the non-custodial
parent(s), establishing paternity, and obtaining a court order to ensure payment of support through the courts. Failure to cooperate could
result in termination of assistance. Any support payments received after the assignment has been executed should be forwarded to the
designated child support agency.
Exception: You may claim good cause for refusing to cooperate in the State’s effort to collect Child Support if you believe that cooperation
would not be in the best interest of the child. The following are circumstances under which it may be determined that you have good cause:
•
cooperation is anticipated to result in serious physical or emotional harm to the child;
•
cooperation is anticipated to result in physical or emotional harm to you which is so serious it reduces your ability to care for the child
adequately;
•
the child was born as a result of rape or incest;
•
court proceedings are on-going for adoption of the child; or
•
you are working with an agency helping you decide whether to place the child for adoption.
If you want to claim good cause, you must:
•
Provide the evidence needed to determine whether you have good cause for refusing to cooperate. If your reason for claiming good cause
is your fear of physical harm and it is impossible to obtain evidence, the Family and Social Services Administration may still be able to
make a good cause determination after an investigation of your claim.
•
Give the necessary evidence to the agency within twenty (20) days after claiming good cause. You will be given more time only if it is
determined that more time is required because of the difficulty in obtaining the evidence.
The Family and Social Services Administration may:
•
Decide your claim based on the evidence which you give to the agency; or
•
Decide to conduct an investigation to further verify your claim. If it is decided that further information is needed, you may be required to
provide that information before a decision is made. The agency will not contact the absent parent without first telling you.
If you are found to have good cause for not cooperating, the Department of Child Services may attempt to establish paternity or collect
support only if a determination has been made that this can be done without risk to you or your child. This will not be done without first
telling you.
The following are examples of acceptable kinds of evidence that can be used in determining if good cause exists. If you need help in getting a
copy of any of the documents, reasonable assistance will be provided to help you obtain the necessary documents to support your claim.
•
Birth certificates, or medical or law enforcement records which indicate that the child was conceived as a result of incest or forcible rape;
•
court documents or other records which indicate that legal proceedings for adoption are pending in court;
•
court, medical, criminal, child protective services, social services, psychological or law enforcement records which indicate that the absent
parent might inflict physical or emotional harm on you or the child;
•
medical records which indicate emotional health history and present health status of you or the child for whom support would be sought or
written statements from a mental health professional indicating a diagnosis concerning the emotional health of you or the child;
•
a written statement from a public or private agency confirming that you are being assisted in resolving the issue of whether to keep or give
up the child for adoption; and
•
signed statements from individuals, including friends, neighbors, clergymen, social workers, and medical professionals who
might have knowledge of the circumstances providing the basis of your good cause claim.
Upon termination of TANF eligibility, the assignment ends with respect to current support. Assignment will not terminate with respect to monies
owed to the state and federal governments due to the provision of public assistance. After termination of assistance, in accordance with state
and federal laws, if the obligor owes current support and/or arrearages to both the former TANF recipient/payee and to the State, current
support and arrearage will be paid first to the former recipient/payee then to the State, with the exception of federal tax offsets which will be
applied first to amounts which the state and federal government are entitled. Support enforcement activities will continue for you although your
TANF has ended unless you notify the Child Support Bureau in writing that these services should be discontinued. If you close your Child
Support enforcement case, you are no longer entitled to services until you apply and pay the required application fee.
2.
When you apply for TANF, you must follow these rules:
⇒
DO NOT make false or misleading statements.
⇒
DO NOT take any action to conceal or withhold facts, misrepresent your situation, or submit false documents.
If you break the above rules, you can be disqualified from the TANF Program six (6) months for the first violation, twelve (12) months for
the second violation and permanently for the third violation.
Page 4 of 5
DFRNRAE04
NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
*DFRNRAE05*
State Form 54105 (R13 / 3-18) / DFR 0009C
SECTION 3 (continued)
3.
THIS SECTION APPLIES ONLY TO CASH ASSISTANCE.
Any individual convicted in a court of a misdemeanor for breaking the rules below can be disqualified from the TANF program for a period
of twelve (12) months for the first and second violations and permanently for the third violation. Those convicted of committing a felony for
breaking the rules can be disqualified for ten (10) years for the first and second violations and permanently for the third violation.
⇒
⇒
DO NOT make false or misleading statements.
DO NOT take any action to conceal or withhold facts, misrepresent your situation, or submit false documents.
4.
While you are on the TANF program, assistance with childcare may be available to you. Childcare assistance may also be available if you
lose TANF eligibility because of earnings.
5.
While you are on the TANF program, you must follow these rules:
•
You will ensure that your children receive their age appropriate immunizations.
•
You will ensure that your school age children regularly attend school.
•
You will ensure that your children are raised in a safe and secure home.
•
You will not use illegal drugs or other substances that would interfere with your ability to become self-sufficient.
•
You will cooperate with the IMPACT program to develop a self-sufficiency plan and you will comply with the requirements specified in the
plan. If you fail or refuse to cooperate with the IMPACT program sanctions may be imposed, including loss of cash benefits.
•
You will not receive additional cash benefits for children who are born more than ten (10) months after the date that you are authorized to
receive TANF benefits.
•
If you are a minor parent, you will reside with the adult who is related to you as a parent, stepparent, or grandparent or an adult who is
your legal guardian
6.
The receipt of TANF cash benefits shall be limited to a total of twenty-four (24) months for adults and sixty (60) months for their families.
7.
As a condition of eligibility, adult applicants deemed mandatory for the IMPACT program will be referred to IMPACT to complete a job search
program. Failure to complete the job search program without good cause is grounds for denying the TANF application.
8.
Under Indiana law (IC12-13-14-4.5), it is a Class C misdemeanor for TANF recipients to use their Hoosier Works electronic benefits (EBT)
card to access TANF benefits at liquor stores, gambling establishments, horse racing facilities, gun stores and adult entertainment
establishments. A person convicted of a Class C misdemeanor can be jailed for up to sixty (60) days and can be fined up to five hundred
dollars ($500).
Page 5 of 5
DFRNRAE05
| File Type | application/pdf |
| File Title | NOTICE REGARDING RIGHTS AND RESPONSIBILITIES |
| Author | ACS |
| File Modified | 2019-08-16 |
| File Created | 2018-03-29 |