Indiana
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049
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
- 49049
DFR: Forms - Reviewed 2026-11-02
- What it is for
- IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049
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
- IMPACT job training
DFR: Forms - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- SNAP
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Client
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049 - Reviewed 2026-11-02
- How to submit
- Not listed yet. Call to confirm.
- Documents to include
- Not listed yet. Call to confirm.
- Languages
- English
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049 - 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=5525
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R8 / 10-20
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049 - Reviewed 2026-11-02
- Signature
- I have read the above Rights and Responsibilities. I understand that any questions I may have regarding the above information will need to be directed to my IMPACT Case Manager. My signature below indicates receipt of this Agreement. Signature of client Date (month, day, year)
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049 - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
Failure to comply with your employment and training requirements will result in the loss of IMPACT supportive services (including child care) and in your removal from the IMPACT Program without loss of benefits or threat of a penalty.
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients 49049 - Reviewed 2026-11-02
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