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Indiana Family and Social Services Administration Forms

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Form 50548 Licensed Child Care Center/Home Consent Form - Indiana PDF

Form 50548 Licensed Child Care Center/Home Consent Form - Indiana
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State Form 53502 Falls Risk Assessment - Indiana PDF

State Form 53502 Falls Risk Assessment - Indiana
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Orientation of New Employees - Indiana PDF

Orientation of New Employees - Indiana
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State Form 53932 Administrative Appeal and Hearing Request - Indiana PDF

State Form 53932 Administrative Appeal and Hearing Request - Indiana
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State Form 55366 (DFR2123HC) Authorized Representative for Health Coverage - Indiana PDF

State Form 55366 (DFR2123HC) Authorized Representative for Health Coverage - Indiana
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State Form 54621 Authorization for Disclosure of Personal and Health Information - Indiana PDF

State Form 54621 Authorization for Disclosure of Personal and Health Information - Indiana
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State Form 51736 (OMPP0051) Revocation of Authorization - Indiana PDF

State Form 51736 (OMPP0051) Revocation of Authorization - Indiana
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State Form 49884 Protective Payee for Hoosier Works Card - Indiana PDF

State Form 49884 Protective Payee for Hoosier Works Card - Indiana
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State Form 53263 (DFR2512) Indiana Application for Snap and Cash Assistance - Indiana PDF

State Form 53263 (DFR2512) Indiana Application for Snap and Cash Assistance - Indiana
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Formulario del Estado 53622 (DFR2512S) Solicitud Para Snap Y Asistencia Cash - Indiana (Spanish) PDF

Formulario del Estado 53622 (DFR2512S) Solicitud Para Snap Y Asistencia Cash - Indiana (Spanish)
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State Form 55367 (DFR0009M) Notice Regarding Rights & Responsibilities for Health Coverage - Indiana PDF

State Form 55367 (DFR0009M) Notice Regarding Rights & Responsibilities for Health Coverage - Indiana
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State Form 47826 (IMP0009) Client Attendance Report - Vocational Educational Training/Job Skills Training - Indiana PDF

State Form 47826 (IMP0009) Client Attendance Report - Vocational Educational Training/Job Skills Training - Indiana
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State Form 49049 (IMP0032) Impact Responsibilities, Sanctions, and Rights Voluntary Clients - Indiana PDF

State Form 49049 (IMP0032) Impact Responsibilities, Sanctions, and Rights Voluntary Clients - Indiana
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State Form 54105 (DFR0009C) Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (Snap) and Cash Assistance - Indiana PDF

State Form 54105 (DFR0009C) Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (Snap) and Cash Assistance - Indiana
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Formulario del Estado 55372 (DFR0009MS) Aviso Relacionado Con Los Derechos Y Las Responsabilidades Para La Cobertura De Salud - Indiana (Spanish) PDF

Formulario del Estado 55372 (DFR0009MS) Aviso Relacionado Con Los Derechos Y Las Responsabilidades Para La Cobertura De Salud - Indiana (Spanish)
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State Form 56195 Indiana Application for Snap and Cash Assistance - Indiana (Burmese) PDF

State Form 56195 Indiana Application for Snap and Cash Assistance - Indiana (Burmese)
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Formulario del Estado 54106 (DFR0009CS) Aviso Relacionado Con Los Derechos Y Las Responsabilidades Del Programa De Asistencia Nutricional Suplementaria Y Asistencia Cash - Indiana (Spanish) PDF

Formulario del Estado 54106 (DFR0009CS) Aviso Relacionado Con Los Derechos Y Las Responsabilidades Del Programa De Asistencia Nutricional Suplementaria Y Asistencia Cash - Indiana (Spanish)
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Formulario del Estado 53461 (DFR2123S) Representante Autorizado SNAP (Asistencia Alimentaria) Y Asistencia Cash - Indiana (Spanish) PDF

Formulario del Estado 53461 (DFR2123S) Representante Autorizado SNAP (Asistencia Alimentaria) Y Asistencia Cash - Indiana (Spanish)
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State Form 46514 Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children - Indiana PDF

State Form 46514 Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children - Indiana
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State Form 48191 (IMP0020) Applicant Job Search Rights and Responsibilities - Indiana PDF

State Form 48191 (IMP0020) Applicant Job Search Rights and Responsibilities - Indiana
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Formulario del Estado 55371 (DFR2123S) Representante Autorizado Cobertura De Salud - Indiana (Spanish) PDF

Formulario del Estado 55371 (DFR2123S) Representante Autorizado Cobertura De Salud - Indiana (Spanish)
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State Form 54530 Fssa Legislative Inquiry: Authorization to Act on Constituent's Behalf - Indiana PDF

State Form 54530 Fssa Legislative Inquiry: Authorization to Act on Constituent's Behalf - Indiana
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Formulario del Estado 54586 (IMP0009S) Registro De Asistencia De Impact Programa De Capacitacion Para La Educacion Vocacional / Capacitacion Para Las Habilidades Laborales - Indiana (Spanish) PDF

Formulario del Estado 54586 (IMP0009S) Registro De Asistencia De Impact Programa De Capacitacion Para La Educacion Vocacional / Capacitacion Para Las Habilidades Laborales - Indiana (Spanish)
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State Form 49228 Application for Medicare Savings Program (Qmb, Slmb, Qi) - Indiana PDF

State Form 49228 Application for Medicare Savings Program (Qmb, Slmb, Qi) - Indiana
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State Form 53460 (DFR2123) Authorized Representative for SNAP (Food Assistance) and Cash Assistance - Indiana PDF

State Form 53460 (DFR2123) Authorized Representative for SNAP (Food Assistance) and Cash Assistance - Indiana
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State Form 49049 Impact Rights and Responsibilities for Snap Volunteers - Indiana PDF

State Form 49049 Impact Rights and Responsibilities for Snap Volunteers - Indiana
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State Form 35937 Claim to Defray Funeral and Cemetery Expenses - Indiana PDF

State Form 35937 Claim to Defray Funeral and Cemetery Expenses - Indiana
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Form OR-FN-HS-NU-36 Patient Intake and Output Record - Indiana PDF

Form OR-FN-HS-NU-36 Patient Intake and Output Record - Indiana
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State Formulario 54586 Registro De Asistencia De Impact - Programa De Capacitacion Para La Educacion Vocacional/Capacitacion Para Las Habilidades Laborales - Indiana (Spanish) PDF

State Formulario 54586 Registro De Asistencia De Impact - Programa De Capacitacion Para La Educacion Vocacional/Capacitacion Para Las Habilidades Laborales - Indiana (Spanish)
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