Indiana
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461
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
- 53461
DFR: Forms - Reviewed 2026-11-02
- What it is for
- Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461
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
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Si usted desea que alguien actúe en su nombre para solicitar los beneficios y/o actuar en su nombre de manera continua, este formulario deberá ser completado. Asegúrese de escoger la(s) función(es) que los representantes están autorizados a desempeñar. Usted puede escoger más de un representante y elegir la misma función o distintas funciones. Complete UN formulario por representante autorizado. Tanto usted como su representante deben firmar y escribir la fecha en este formulario.
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461 - Reviewed 2026-11-02
- How to submit
- General DFR forms-catalog route: fax 888-436-9199, or deliver or mail to your local county office. Follow document-specific instructions where supplied.
DFR: Forms - Reviewed 2026-11-02
- Documents to include
- (Si el solicitante/beneficiario está impedido médicamente para firmar la autorización, suministrar la documentación médica).
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461 - Reviewed 2026-11-02
- 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=9519
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R5 / 12-17
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461 - Reviewed 2026-11-02
- Signature
- Tanto usted como su representante deben firmar y escribir la fecha en este formulario.
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461 - Reviewed 2026-11-02
- Accessibility
- Not listed yet. Call to confirm.
- What the form says
Entiendo que soy responsable por la información suministrada por cualquiera que actúe como mi representante autorizado, incluyendo cualquier información que pueda ser incorrecta. También entiendo que si en algú n momento deseo que la(s) persona(s) que escojo dejen de ser mi representante autorizado es mi responsabilidad comunicarme con la División de Recursos para la Familia (Division of Family Resources, en inglés).
Authorized Representative for SNAP (food assistance) and Cash Assistance (Spanish) 53461 - Reviewed 2026-11-02
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