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Authorized Representative For Snap (Food Assistance) and Cash Assistance

This document authorizes a representative to act on behalf of an applicant for SNAP (food assistance) and cash assistance benefits. The representative must complete their contact information and sign agreeing to be knowledgeable about the applicant's situation. The applicant then selects which functions the representative can perform, such as applying for benefits, receiving notices, or accessing benefits via an EBT card. By signing, the applicant allows the representative to act on their behalf for the authorized functions and takes responsibility for any incorrect information provided. The applicant can revoke the authorization at any time.

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Paul
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156 views1 page

Authorized Representative For Snap (Food Assistance) and Cash Assistance

This document authorizes a representative to act on behalf of an applicant for SNAP (food assistance) and cash assistance benefits. The representative must complete their contact information and sign agreeing to be knowledgeable about the applicant's situation. The applicant then selects which functions the representative can perform, such as applying for benefits, receiving notices, or accessing benefits via an EBT card. By signing, the applicant allows the representative to act on their behalf for the authorized functions and takes responsibility for any incorrect information provided. The applicant can revoke the authorization at any time.

Uploaded by

Paul
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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AUTHORIZED REPRESENTATIVE *DFR03AE01*

FOR SNAP (FOOD ASSISTANCE)


AND CASH ASSISTANCE
State Form 53460 (R5 / 12-17) / DFR 2123

Section 1
If you want someone to act on your behalf in applying for benefits and/or act for you on an ongoing basis, this form must be completed. Be sure to
select the function(s) that the representative is being authorized to do. You can select more than one representative and choose the same or
different functions. Complete ONE form per authorized representative. Both you and your representative must sign and date this form.

Section 2
Name of Representative (Please print clearly):

Check association with applicant/recipient. Please select ONE (1).


Attorney Eligibility Assistance Company Friend Family

Institution of Residence Waiver Case Manager Other (Specify): _______________________________

Mailing Address (number and street, city, state, and ZIP code):

SELECT THE FUNCTION(S) THE AUTHORIZED


REPRESENTATIVE WILL DO:
FUNCTION FUNCTION DESCRIPTION SNAP CASH ASSISTANCE
 Sign application and be interviewed.
 Provide all required proof of information necessary to determine eligibility for
Apply Apply
APPLY benefits.
 Receive the Notice of the application decision.
 Speak on applicant’s behalf at a hearing if the application decision is appealed.
 Report changes.
 Attend periodic redeterminations.
Ongoing Ongoing
ONGOING  Receive the appointment notices and any redetermination mail-in forms.
NOTE: Do not check this function if the representative will not continue to act on
recipient’s behalf after the application decision is made.
 Get a Hoosier Works Card to access recipient’s SNAP benefits or Cash Assistance.
 Receive and use benefits on behalf of recipient’s household.
If one of the EBT boxes are selected, complete the following for the Authorized
EBT EBT
EBT Representative:
Date of Birth (mm/dd/yyyy): Social Security Number:

In agreeing to be the authorized representative, I understand that I am expected to be knowledgeable of the applicant’s/recipient’s circumstances and that this
authorization can be revoked by the applicant/recipient at any time.
Signature: Date (mm/dd/yyyy): Telephone ((###) ###-####):

Section 3
I authorize this representative to act for me in taking care of the functions and program eligibility process which I have checked above. (If applicant/recipient is
medically incapable to sign authorization, provide medical documentation.) I understand that I am responsible for the information anyone acting as my
authorized representative gives, including any information that may be incorrect. I also understand that if at any time I wish to stop the person(s) I chose from
being my authorized representative, it is my responsibility to contact the Division of Family Resources.
Applicant/Recipient Name Applicant/Recipient Signature Date (mm/dd/yyyy):

Case Number (Optional): Applicant/Recipient Date of Birth (mm/dd/yyyy) Applicant/Recipient Social Security Number

XXX-XX-

DFR03AE01

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