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Blank State 53263 Indiana Form

The State Form 53263 is the Indiana application for SNAP (Supplemental Nutrition Assistance Program) and cash assistance. This form is essential for individuals seeking financial support to meet their basic needs. Completing it accurately can help expedite the assistance process and ensure that applicants receive the help they need.

Outline

The State Form 53263, known as the Indiana Application for SNAP and Cash Assistance, serves as a crucial document for individuals seeking food and financial assistance. This application requires applicants to provide essential information, including personal details such as names, addresses, and contact information. It also includes sections for individuals applying on behalf of someone else. To facilitate the process, applicants should complete all relevant sections, particularly Section 8, if they wish to be considered for expedited SNAP services. Important eligibility criteria are outlined within the form, including income thresholds and the necessity of verifying information provided. Additionally, the form emphasizes the significance of signatures, which affirm the accuracy of the information and acknowledge the potential consequences of providing false details. By following the instructions carefully and providing complete information, applicants can enhance their chances of receiving the assistance they need.

Sample - State 53263 Indiana Form

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)

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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

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Form Information

Fact Name	Details
Form Title	Indiana Application for SNAP and Cash Assistance
Form Number	State Form 53263 (R8 / 6-13) / DFR 2512
Governing Law	7 CFR 273.2(b)(1)(i) and 42 USC SECTION 602(a)(26)
Application Requirements	Name, address, and signature are mandatory for validity.
Expedited Service Criteria	Household must have less than $150 in monthly gross income and $100 or less in cash.
Signature Requirement	Signature and date are required to validate the application.
Contact Information	Applicant must provide contact details if applying on behalf of someone else.
Utility Payments	Applicants must disclose if they pay for heating or cooling, or other utilities.
Voting Registration	Applicants can choose to register to vote, which does not affect eligibility for benefits.

Detailed Guide for Filling Out State 53263 Indiana

Filling out the State Form 53263 is an important step in applying for assistance in Indiana. It is crucial to provide accurate information to ensure a smooth processing of your application. After completing the form, you will submit it to the appropriate agency for review. Be prepared for any follow-up questions or additional documentation that may be required.

Gather necessary information: Collect details such as names, addresses, Social Security numbers, and income information for everyone in your household.
Complete Section 1: If you are applying on behalf of someone else, provide your name and contact information. If you live with the applicant, fill out your information in Section 9.
Fill out Section 2: Provide information for the person needing assistance. Indicate the type of help they need (SNAP or Cash Assistance) and answer questions about their identity, including date of birth and gender.
Complete Section 3: Sign and date the application to certify that the information provided is correct.
Provide mailing address: If different from the home address, fill out Section 4 with the appropriate details.
List alternate contact information: In Section 5, include alternate telephone numbers and an email address if applicable.
Complete Section 8: If applying for expedited SNAP service, answer all questions regarding income and expenses.
Fill out Section 9: Provide information for additional household members, as necessary. Ensure to check the type of help they need.
Indicate your interview preference: In Section 10, choose whether you prefer a telephone or in-person interview.
Complete final sections: Answer questions about automated calls and voter registration in Sections 11 and 12.

Obtain Answers on State 53263 Indiana

What is the State Form 53263 in Indiana?

The State Form 53263 is an application for the Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance in Indiana. This form is essential for individuals seeking financial aid for food and cash assistance, including Temporary Assistance for Needy Families (TANF) or Refugee assistance.
Who can fill out this application?

The application can be completed by the individual seeking assistance or by someone acting on their behalf. If you are completing the form for someone else, it is crucial to provide your contact information and specify your relationship to the applicant.
What information do I need to provide on the form?

Applicants must provide their name, address, and signature. Additional details include Social Security numbers, date of birth, income information, and household composition. Completing all sections, especially Section 8 for expedited SNAP service, is highly recommended.
What is expedited SNAP service?

Expedited SNAP service is designed for individuals who need immediate assistance. To qualify, your household must have less than $150 in monthly gross income and $100 or less in cash. Alternatively, seasonal or migrant farm workers can also apply under specific conditions. Completing Section 8 of the form is necessary to be considered for this service.
What happens if I provide incorrect information?

Providing incorrect information can lead to denial of benefits. It may also result in criminal prosecution for knowingly submitting false information. Therefore, it is vital to ensure that all information provided is accurate and complete.
Do I need to sign the application?

Yes, a signature is required. By signing, you acknowledge that the information provided is subject to verification and that you understand the rights and responsibilities associated with receiving assistance.
Can I apply for assistance if I have a felony conviction?

Individuals fleeing felony prosecution or those with felony convictions related to controlled substances are generally ineligible for SNAP and TANF benefits. It is essential to review eligibility requirements carefully before applying.
How can I submit my completed application?

You can submit your completed application by mailing it to the appropriate Division of Family Resources office. Ensure that you keep a copy for your records. You may also be able to submit it in person, depending on local office procedures.
What if I need assistance during the application process?

If you need help while filling out the application, you can contact the Indiana Division of Family Resources. They can provide guidance and answer any questions you may have about the process or specific sections of the form.
Will applying for assistance affect my ability to vote?

No, your application for SNAP or Cash Assistance will not impact your voting rights. You can choose to register to vote on the application, but it is not a requirement, and your eligibility for benefits remains unaffected.

Common mistakes

Completing the State Form 53263 for Indiana can be straightforward, but many people make common mistakes that can delay the process. One frequent error is failing to provide complete information. While the form allows for some flexibility, missing details can lead to a rejection of the application. Ensure that you fill out all required sections, especially your name, address, and signature, as these are critical for processing.

Another mistake is neglecting to sign the application. This seems simple, but many applicants forget to sign in Section 3 on Page 1. Without a signature, the application is not valid, and you may have to start over. Always double-check that your signature is present before submitting.

Some individuals also overlook the importance of Section 8, which pertains to expedited SNAP services. If you want to be considered for faster assistance, it is essential to answer all questions in this section. Missing even one question can disqualify you from expedited service, leading to longer wait times for assistance.

Providing incorrect or outdated information is another common pitfall. Ensure that all personal details, such as Social Security numbers and dates of birth, are accurate. Mistakes in this area can complicate the verification process and may result in denial of benefits.

Many applicants forget to include additional individuals who live at their address. If you are applying for assistance on behalf of a household, all members must be listed in Section 9. Failing to do so can lead to incomplete applications and delays in processing.

Additionally, some people fail to indicate their relationship to the person needing assistance if they are completing the application on someone else's behalf. This information is crucial for the application to be processed correctly, so make sure to clarify your relationship in Section 7.

Finally, many applicants do not take the time to read the instructions thoroughly. Skimming the guidelines can result in overlooking important requirements. Take a moment to review the instructions to ensure that you meet all necessary criteria before submitting your application.

Documents used along the form

When completing the Indiana Application for SNAP and Cash Assistance (State Form 53263), several other forms and documents may be required to ensure a smooth application process. Below is a list of commonly used documents that can accompany this application. Each document serves a specific purpose and may help in verifying eligibility for assistance.

Authorized Representative Form: This form allows someone to act on behalf of the applicant, providing them the authority to discuss the application and receive information related to it.
Proof of Income: Documentation such as pay stubs, tax returns, or benefit statements that verify the household's income. This is crucial for determining eligibility for SNAP and cash assistance.
Proof of Identity: A government-issued ID, such as a driver's license or passport, is needed to confirm the identity of the applicant and any household members.
Proof of Residency: Documents like a utility bill or lease agreement that show the applicant's current address. This is essential for verifying residency in Indiana.
Social Security Number Verification: A document that confirms the Social Security numbers of all household members, which is required for processing the application.
Medical Expenses Documentation: Receipts or statements showing medical expenses may be required if the applicant is seeking deductions that affect eligibility calculations.
Child Support Documentation: If applicable, any court orders or agreements related to child support must be provided to verify income and obligations.
Immigration Status Documentation: For non-citizens, proof of immigration status may be necessary to determine eligibility for benefits.
Utility Bills: Recent bills can be used to verify expenses that may impact the eligibility for SNAP benefits.

Gathering these documents can help streamline the application process and ensure that all necessary information is submitted for review. It is important to provide complete and accurate information to facilitate a timely decision regarding assistance.

Similar forms

The State Form 53263, used for applying for SNAP and Cash Assistance in Indiana, shares similarities with several other documents related to social assistance programs. Below is a list of nine documents that are comparable in purpose or structure:

State Form 53264: This form is also used for applying for assistance but specifically focuses on the Temporary Assistance for Needy Families (TANF) program. It collects similar personal and household information to determine eligibility.
State Form 53265: This document serves as a renewal application for SNAP benefits. It requires updated information about household income and expenses, mirroring the initial application process of Form 53263.
State Form 53266: This form is intended for reporting changes in circumstances for individuals already receiving SNAP or TANF. It asks for similar details regarding income and household composition, akin to the information required on Form 53263.
State Form 53267: This application is for the Medicaid program in Indiana. Like Form 53263, it requires personal details, income information, and household size to assess eligibility for benefits.
State Form 53268: This form is used for the Supplemental Nutrition Assistance Program (SNAP) for college students. It shares many of the same questions as Form 53263, focusing on financial and household information.
State Form 53269: This is a request for expedited SNAP service. It parallels Section 8 of Form 53263, asking for urgent financial information to determine immediate eligibility for assistance.
State Form 53270: This form is utilized for applying for the Low-Income Home Energy Assistance Program (LIHEAP). It collects similar demographic and financial information to determine eligibility for energy assistance.
State Form 53271: This document serves as an application for Refugee Cash Assistance. It requires similar information to Form 53263, focusing on the financial needs of refugees.
State Form 53272: This form is used for the Women, Infants, and Children (WIC) program. It gathers personal and household data to assess eligibility, similar to the structure of Form 53263.

Dos and Don'ts

When filling out the State Form 53263 for Indiana, it's important to follow specific guidelines to ensure a smooth application process. Below is a list of things you should and shouldn't do.

Do fill out the application completely, providing all requested information.
Do ensure you sign the application on Page 1, Section 3.
Do provide your contact information if completing the application for someone else.
Do check all relevant boxes regarding the assistance needed.
Do include information about all individuals living in the household.
Don't leave out any required sections, especially if applying for expedited service.
Don't forget to provide a valid mailing address if it differs from your home address.
Don't skip questions regarding income and expenses, as they are crucial for determining eligibility.
Don't submit the application without reviewing it for accuracy and completeness.

Misconceptions

Understanding the State Form 53263 for Indiana can be challenging. Here are seven common misconceptions about this form:

It's only for food assistance. Many believe this form is solely for SNAP benefits. In reality, it also applies to cash assistance programs like TANF.
You can skip sections if you don’t have all the information. While it’s valid to submit the form with basic details, providing complete information helps ensure a smoother application process.
Only the applicant needs to sign. Some think only the person applying must sign. However, if someone is applying on behalf of another, that representative must also provide their information and signature.
Expedited service is automatic. Many assume they will receive expedited service just by applying. To qualify, specific criteria must be met, such as income limits.
Social Security numbers are optional for everyone. While it’s true that providing a Social Security number is optional for those not applying, it’s mandatory for the primary applicant and any other household members applying for assistance.
Eligibility is only based on income. Some people think that income is the only factor. Other aspects, such as citizenship status and criminal history, also play a crucial role in determining eligibility.
You can submit the form without a signature. It’s a common misconception that a form can be submitted unsigned. A signature is required to validate the application and affirm the information provided.

Clarifying these misconceptions can help ensure a more effective application process for those seeking assistance in Indiana.

Key takeaways

Key Takeaways for Completing the State Form 53263 in Indiana

Provide essential information such as your name, address, and signature to ensure your application is valid.
If you are applying for expedited SNAP service, complete all of Section 8, detailing your household income and expenses.
Make sure to sign your application on Page 1, Section 3, as this is a critical step in the process.
If you are completing the application for someone else, include your contact information in Section 7, and clarify your relationship to the applicant.
Remember that providing accurate information is crucial; incorrect details may lead to denial of benefits or legal consequences.