State Form 53932 "Administrative Appeal and Hearing Request" - Indiana

What Is State Form 53932?

This is a legal form that was released by the Indiana Department of Family & Social Services Administration - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the Indiana Department of Family & Social Services Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of State Form 53932 by clicking the link below or browse more documents and templates provided by the Indiana Department of Family & Social Services Administration.

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Download State Form 53932 "Administrative Appeal and Hearing Request" - Indiana

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ADMINISTRATIVE APPEAL AND HEARING
REQUEST
State Form 53932 (R /2-12) / H&A 1001
******THIS FORM MAY BE USED TO FILE A WRITTEN ADMINISTRATIVE APPEAL.******
FOOD STAMP APPEALS MAY BE ALSO FILED VERBALLY BY CALLING
1-800-403-0864.
Name:
___________________________________________________
Address:
___________________________________________________
___________________________________________________
Phone number: ___________________________________________________
Relationship:
___________________________________________________
(self, spouse, representative, relative)
Signature: ________________________________________
Date (month, day, year): ________________
Did you receive a written notice about the denial, termination or change of your benefits?  YES  NO
Mailing date of the notice (if known) ___________
Case number shown on the notice: _ ____________
List of names of persons you are appealing for, including yourself:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
What benefits are you appealing?
Benefit was:
 Denied
 Terminated / Closed
 Changed
TANF
 Denied
 Terminated / Closed
 Changed
Medicaid
 Denied
 Terminated / Closed
 Changed
HIP (Healthy Indiana Plan)
 Denied
 Terminated / Closed
 Changed
Food Stamp
 Denied
 Terminated / Closed
 Changed
Child Care (CCDF)
 Denied
 Terminated / Closed
 Changed
Other - Explain
Mail or fax your request to the location listed below or you may deliver your request in person at the local
Division of Family Resources office. If possible, please attach a copy of the notice you are appealing.
:
Mail or fax to
FSSA Document Center
PO Box 1810
Marion, Indiana 46952
Fax: 1-800-403-0864
ADMINISTRATIVE APPEAL AND HEARING
REQUEST
State Form 53932 (R /2-12) / H&A 1001
******THIS FORM MAY BE USED TO FILE A WRITTEN ADMINISTRATIVE APPEAL.******
FOOD STAMP APPEALS MAY BE ALSO FILED VERBALLY BY CALLING
1-800-403-0864.
Name:
___________________________________________________
Address:
___________________________________________________
___________________________________________________
Phone number: ___________________________________________________
Relationship:
___________________________________________________
(self, spouse, representative, relative)
Signature: ________________________________________
Date (month, day, year): ________________
Did you receive a written notice about the denial, termination or change of your benefits?  YES  NO
Mailing date of the notice (if known) ___________
Case number shown on the notice: _ ____________
List of names of persons you are appealing for, including yourself:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
What benefits are you appealing?
Benefit was:
 Denied
 Terminated / Closed
 Changed
TANF
 Denied
 Terminated / Closed
 Changed
Medicaid
 Denied
 Terminated / Closed
 Changed
HIP (Healthy Indiana Plan)
 Denied
 Terminated / Closed
 Changed
Food Stamp
 Denied
 Terminated / Closed
 Changed
Child Care (CCDF)
 Denied
 Terminated / Closed
 Changed
Other - Explain
Mail or fax your request to the location listed below or you may deliver your request in person at the local
Division of Family Resources office. If possible, please attach a copy of the notice you are appealing.
:
Mail or fax to
FSSA Document Center
PO Box 1810
Marion, Indiana 46952
Fax: 1-800-403-0864