Indiana FSSA Authorized Representative Form (State Form 53460)

DFR needs authorization to share case information and conduct benefit business with someone representing an applicant. State Form 53460 is the authorized-representative form for SNAP and cash assistance, including TANF.

What State Form 53460 Does

State Form 53460 designates you as an authorized representative for SNAP and cash assistance cases. Depending on the functions selected, you can:

• Sign an application and represent the applicant during an interview
• Receive and respond to notices from DFR
• Provide required verification and speak for the applicant at an appeal
• Handle ongoing tasks such as reporting changes and attending redeterminations

Without authorization, DFR may be unable to discuss the case with you or send notices to you as the representative.

How to Complete It

The form asks for:

1. Your identifying information — name, address, and contact information
2. The child's information — name, date of birth, case number (if one already exists)
3. The functions you will perform — application, ongoing case tasks, or EBT functions, as applicable
4. Signatures — the applicant and designated representative sign as directed on the form

FSSA can generate the authorized-representative form after you complete an online application, and the paper application packet includes one. Each barcoded form is case-specific; do not copy it for another case. Follow the current form instructions to submit it. For an existing case, the FSSA page lists fax 888-436-9199 or the FSSA Centralized Document Center, P.O. Box 1810, Marion, IN 46952.

State Form 55366: Health Coverage Specifically

State Form 55366 is the authorized-representative form for health coverage applications (Hoosier Healthwise and Medicaid). Use it for health coverage cases; it is separate from Form 53460 for SNAP and cash assistance.

The distinction matters because each form applies to different assistance types. Complete the form for each type of case for which you need to be authorized.

Common Mistakes

Not completing an authorization. Living with the child does not by itself make you the applicant's authorized representative. If you need DFR to share notices or discuss the case with you, complete the appropriate authorization and follow the case-specific form instructions.

Not completing the generated authorization. If you apply online, complete the authorization form generated after the application. If you do not receive one, contact DFR about adding an authorized representative to the case.

Incomplete signatures. The applicant and designated representative should sign the form as directed. If the applicant cannot provide the required authorization, ask DFR what documentation it accepts.

Keep Your Copies

Fax the form and print the transmission confirmation. If you mail it, send it certified or take a photo of the completed form before mailing. DFR offices handle thousands of documents, and proving you submitted the form on a specific date can matter if there's a delay.

The Indiana Kinship Financial Help Guide includes both forms in its DFR Application Document Prep Checklist, with field-by-field instructions and submission tracking.

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