Indiana
Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105
No One Left Outside provides source-based information. The issuing agency or plan decides eligibility, acceptance and availability.
Source / last checked DFR: Forms - 2026-11-02
- Form number
- 54105
DFR: Forms - Reviewed 2026-11-02
- What it is for
- Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105
DFR: Forms - Reviewed 2026-11-02
- Issuing agency
- Indiana Family and Social Services Administration (FSSA); this form appears in the DFR forms catalog.
DFR: Forms - Reviewed 2026-11-02
- Program
- SNAP and cash assistance
DFR: Forms - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- SNAP
Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Not listed yet. Call to confirm.
- How to submit
- Not listed yet. Call to confirm.
- Documents to include
- Not listed yet. Call to confirm.
- Languages
- English
Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105 - Reviewed 2026-11-02
- Official page
- https://www.in.gov/fssa/dfr/forms-documents-and-tools/forms
DFR: Forms - Reviewed 2026-11-02
- Direct form link
- https://forms.in.gov/Download.aspx?id=10672
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R23 / 12-25
Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105 - Reviewed 2026-11-02
- Signature
- Not listed yet. Call to confirm.
- Accessibility
- Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.), should contact the State or local agency that administers the program or contact the USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105 - Reviewed 2026-11-02
- What the form says
You must provide complete and correct information to the best of your knowledge. A person who receives benefits by intentionally giving false information or by failing to report information may be criminally prosecuted under State and Federal law.
Notice Regarding Rights and Responsibilities for Supplemental Nutrition Assistance Program (SNAP) and Cash Assistance 54105 - Reviewed 2026-11-02
Check the form number and revision before using it. Read the agency's privacy and consent terms before sharing personal information.