The State Form 53263 is the Indiana Application for SNAP and Cash Assistance. This form is essential for individuals seeking food assistance and cash benefits through the state. Completing it accurately is crucial to ensure you receive the support you need.
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The State Form 53263 is crucial for individuals seeking assistance through the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) in Indiana. Along with this form, several other documents and forms may be required or beneficial during the application process. Below is a list of commonly used forms and documents that accompany the State Form 53263.
Collecting and submitting these documents along with the State Form 53263 can streamline the application process and enhance the chances of receiving timely assistance. Ensuring that all required information is complete and accurate is vital for eligibility determination.
Not providing complete information: It's essential to fill out all sections of the form as completely as possible. Incomplete applications can lead to delays or denials of benefits.
Forgetting to sign the application: Remember to sign your application on Page 1, Section 3. Without a signature, the application is not valid.
Incorrectly filling out personal details: Double-check names, dates of birth, and Social Security Numbers. Errors in this information can cause significant issues in processing your application.
Neglecting to indicate household size: Be sure to report how many people live at your address. This information is crucial for determining eligibility and benefit amounts.
Missing the expedited service section: If you need expedited SNAP service, complete all questions in Section 8. Failing to do so can result in delays in receiving assistance.
Not checking the right boxes: When indicating what help is needed, ensure you check the correct boxes for SNAP or Cash Assistance. This guides the application process.
Overlooking additional income sources: Report all sources of income, even if they are zero. This includes earned and unearned income, as omitting information can lead to misunderstandings.
Failing to provide contact information: If you are applying on behalf of someone else, include your contact details in Section 7. This ensures that the agency can reach you if necessary.
When filling out the State Form 53263 for Indiana, there are several important points to keep in mind:
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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.
Not Applying
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?
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
*DFRAAHE02*
4.Mailing Address (if different than home address):
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
Telephone number:
Do you live with the person(s) needing assistance?
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?
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?
If yes, will you receive income from your former employer after today?
Will you receive more than $25 income from your new employer within 10 days?
Has everyone in your household (including you) been approved to receive SNAP benefits this month?
Page 2 of 5
*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.
MI
Last Name
Relationship to person needing assistance listed in Section 2:
Page 3 of 5
*DFRAAHE04*
Page 4 of 5
*DFRAAHE05*
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?
(Examples of calls you may receive are appointment reminders or due dates for requested documents.)
12.
Do you want to register to vote?
Your answer will not affect your eligibility for benefits.
Page 5 of 5