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Blank State 53263 Indiana PDF Template

The State Form 53263 in Indiana is the official application for SNAP (Supplemental Nutrition Assistance Program) and cash assistance. This form allows individuals and families to apply for essential food and financial support. Completing the application accurately is crucial for determining eligibility and ensuring timely assistance.

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Outline

The State Form 53263, known as the Indiana Application for SNAP and Cash Assistance, serves as a crucial tool for individuals seeking financial support through the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). This application is designed to gather essential information about the applicant and their household, ensuring that all necessary details are captured to facilitate the approval process. Key sections of the form require the applicant's personal information, including their name, address, and contact details, along with the specifics of the assistance needed. It is important to note that while completing the application, providing comprehensive answers will enhance the chances of approval, particularly for expedited SNAP services, which have specific income and cash requirements. Moreover, the form includes sections for individuals applying on behalf of someone else, as well as additional questions about household members, ensuring that all eligible individuals are accounted for. Signatures and dates are mandatory, emphasizing the importance of accuracy and honesty in the information provided, as any discrepancies could lead to denial of benefits. The application also outlines the responsibilities of the applicant, including cooperation with work registration and potential verification of the information submitted. Overall, Form 53263 is a vital step for many Indiana residents in accessing essential food and financial assistance programs.

Form Sample

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?

Yes

Marital Status:

Single

Married

Divorced

Separated

Widowed

Ethnicity:

Hispanic or Latino?

Yes

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

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

Last Name

Suffix

Date of Birth (mm-dd-yyyy)

Social Security Number

Gender:

US Citizen?

Yes

Marital Status:

Single

Married

Divorced

Separated

Widowed

Ethnicity:

Hispanic or Latino?

Yes

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

Last Name

Suffix

Date of Birth (mm-dd-yyyy)

Social Security Number

Gender:

US Citizen?

Yes

Marital Status:

Single

Married

Divorced

Separated

Widowed

Ethnicity:

Hispanic or Latino?

Yes

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

Last Name

Suffix

Date of Birth (mm-dd-yyyy)

Social Security Number

Gender:

US Citizen?

Yes

Marital Status:

Single

Married

Divorced

Separated

Widowed

Ethnicity:

Hispanic or Latino?

Yes

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

Last Name

Suffix

Date of Birth (mm-dd-yyyy)

Social Security Number

Gender:

US Citizen?

Yes

Marital Status:

Single

Married

Divorced

Separated

Widowed

Ethnicity:

Hispanic or Latino?

Yes

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

Last Name

Suffix

Date of Birth (mm-dd-yyyy)

Social Security Number

Gender:

US Citizen?

Yes

Marital Status:

Single

Married

Divorced

Separated

Widowed

Ethnicity:

Hispanic or Latino?

Yes

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

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

12.

Do you want to register to vote?

Yes

Your answer will not affect your eligibility for benefits.

Page 5 of 5

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Form Specifics

Fact Name	Details
Form Title	Indiana Application for SNAP and Cash Assistance
Form Number	State Form 53263 (R8 / 6-13) / DFR 2512
Purpose	This form is used to apply for SNAP (Food Assistance) and Cash Assistance (TANF or Refugee) in Indiana.
Required Information	Applicants must provide their name, address, and signature for the application to be valid.
Expedited Service Criteria	To qualify for expedited SNAP service, households must have less than $150 in monthly gross income and $100 or less in cash.
Legal Governing Laws	The application is governed by federal regulations, specifically 7 CFR 273.2(b)(1)(i) and 42 USC SECTION 602(a)(26).
Signature Requirement	A signature and date are required on the form to certify that the information provided is complete and correct.

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