Indiana
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465
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
- 54465
DFR: Forms - Reviewed 2026-11-02
- What it is for
- IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465
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
- IMPACT
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Cliente
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465 - Reviewed 2026-11-02
- How to submit
- Not listed yet. Call to confirm.
- Documents to include
- Not listed yet. Call to confirm.
- Languages
- Spanish edition
DFR: Forms - 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=8823
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R2 / 12-15
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465 - Reviewed 2026-11-02
- Signature
- Firma del cliente Fecha (mes, día, año)
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465 - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
Para los beneficiarios de TANF El incumplimiento de las responsabilidades arriba mencionadas sin una causa justificada podría resultar en una pérdida de los beneficios de Medicaid para el miembro no cumplidor y todo el grupo de asistencia (AG, siglas en inglés) perderá los beneficios de apoyo de IMPACT (incluyendo el cuidado de los hijos) y los beneficios de Asistencia Temporaria para las Familias Necesitadas (Temporary Assistance For Needy Families, TANF, en inglés) a partir del 1 de noviembre de 2011, como se indica a continuación:
IMPACT Responsibilities, Sanctions, and Rights Voluntary Clients (Spanish) 54465 - Reviewed 2026-11-02
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