State Form 53263 Indiana – Fill Out and Use This PDF

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

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

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

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

City

State

Zip Code

6. E-mail address:

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

Street Address

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.

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

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

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: