Indiana
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530)
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Source / last checked DFR: Forms - 2026-11-02
- Form number
- 54530
DFR: Forms - Reviewed 2026-11-02
- What it is for
- FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530)
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
- T o which FSSA Program Area should your inquiry be directed? (For example, Indiana Medicaid, Division of Family Resources, Division of Aging, Hoosier Healthwise, Division of Disability & Rehabilitative Services, Division of Mental Health & Addiction, etc. If unsure, specify FSSA.)
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- FSSA legislative inquiry
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Personal Representatives must sign on behalf of the individual; it is FSSA’s policy to verify that an individual’s personal representative is identified as such in our files prior to acting on this authorization.
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - Reviewed 2026-11-02
- How to submit
- Not listed yet. Call to confirm.
- Documents to include
- Please describe your concern. Attach additional pages as necessary.
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - Reviewed 2026-11-02
- Languages
- English
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - 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=9423
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R / 3-14
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - Reviewed 2026-11-02
- Signature
- Signature Having had full opportunity to read and consider the contents of this authorization, including my rights and the risks of fur - ther disclosure as described above, I am authorizing FSSA to disclose my personal information, including health information, to the state legislator (including their staff) named above. I understand the applicable FSSA Program Area(s) will disclose only that information which is necessary to address my stated concern—the information disclosed will be limited to the minimum necessary. I also understand that I am under no obligation to sign this authorization. I understand that the services and ben - efits that may be provided to me by or through FSSA will not be affected whether or not I sign this form. Signature Date Personal Representatives must sign on behalf of the individual; it is FSSA’s policy to verify that an individual’s personal representative is identified as such in our files prior to acting on this authorization.
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
This authorization will automatically expire sixty (60) calendar days from the date you sign it. You may specify an earlier or later expiration date, or you may specify an event upon which this authorization will expire (e.g., “when my concern has been addressed”). Please select one of the following three:
FSSA Legislative Inquiry: Authorization to Act on Constituent's Behalf (state form 54530) - 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.