FSSA Application Document
FSSA Document Center P.O. Box 1810 Marion IN 46952
*DFRMLAE01007AH3P4*
*DFRMLAE01007AH3P4*
Santoshi R Naidu 2612 Eastgate Lane Apt: Apt G Bloomington, IN 47408
APPLICATION DOCUMENT COVER SHEET
State Form 53678 (R2 / 1-11) / DFR 1011
*DFRASAE01007AH3P3*
Instructions
Please fill out and submit this form when you send copies of documents that we have asked you to provide. A list of the documents to provide is in the Information to Get You Started instructions included with your application. When you have filled out this form, place it on top of the copies of your documents and mail or fax it and your copies to: Mailing Address: FSSA Document Center PO Box 1810 Marion, Indiana 46952 Fax Number: 1-800-403-0864
To fill out the form, please complete the Documents Included section below using a blue or black ink pen. Place an X in the box next to each document that you are sending us. Example: X Utility Bill If a document that you are sending us is not listed, then place an X in the box next to ‘Other(s)’ and write the name of the document(s) on the line provided. Please send copies of the documents instead of originals. Write your name and Social Security Number on each item you fax or mail. This form should be used to provide information for your household only. You may copy this form before filling it out and save it to use later if you cannot send in all of the requested documents now. If you have questions, please call us toll-free at (1-800-403-0864) between 8:00 AM and 4:30 PM Monday through Friday. Identity Money Received (con’t) Resources (con’t) Child Care / Child Support Expenses
□ Driver’s License □ State Photo ID Card □ Student Photo ID
Social Security Number
□ Disability Payments □ Employer Statement □ Employer Statement of
Termination
□ Stock / Bond Statement or
Certificate
□ Trust Statement □ Vehicle Registration
Insurance
□ County Clerk Record for
Child Support
□ Proof of Child Support
*DFRMLAE01007AH3P4*
*DFRMLAE01007AH3P4*
Santoshi R Naidu 2612 Eastgate Lane Apt: Apt G Bloomington, IN 47408
APPLICATION DOCUMENT COVER SHEET
State Form 53678 (R2 / 1-11) / DFR 1011
*DFRASAE01007AH3P3*
Instructions
Please fill out and submit this form when you send copies of documents that we have asked you to provide. A list of the documents to provide is in the Information to Get You Started instructions included with your application. When you have filled out this form, place it on top of the copies of your documents and mail or fax it and your copies to: Mailing Address: FSSA Document Center PO Box 1810 Marion, Indiana 46952 Fax Number: 1-800-403-0864
To fill out the form, please complete the Documents Included section below using a blue or black ink pen. Place an X in the box next to each document that you are sending us. Example: X Utility Bill If a document that you are sending us is not listed, then place an X in the box next to ‘Other(s)’ and write the name of the document(s) on the line provided. Please send copies of the documents instead of originals. Write your name and Social Security Number on each item you fax or mail. This form should be used to provide information for your household only. You may copy this form before filling it out and save it to use later if you cannot send in all of the requested documents now. If you have questions, please call us toll-free at (1-800-403-0864) between 8:00 AM and 4:30 PM Monday through Friday. Identity Money Received (con’t) Resources (con’t) Child Care / Child Support Expenses
□ Driver’s License □ State Photo ID Card □ Student Photo ID
Social Security Number
□ Disability Payments □ Employer Statement □ Employer Statement of
Termination
□ Stock / Bond Statement or
Certificate
□ Trust Statement □ Vehicle Registration
Insurance
□ County Clerk Record for
Child Support
□ Proof of Child Support