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  • Indiana State Form 55366

Get Indiana State Form 55366

AUTHORIZED REPRESENTATIVE FOR HEALTH COVERAGE *DFRAZAE01* State Form 55366 (R2 / 1214) / DFR 2123HC Section 1 If you want someone to act on your behalf in applying for benefits and/or act for you.

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The “Interim Report” is one of the ways DTA ensures you are still eligible for SNAP and helps DTA keep up with any changes that affect your benefits.

Fax: 800-403-0864 or deliver or mail to your local county office.

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

Establishing an Authorized Representative with the state The form needs to be signed by you and the person you authorize as your representative. It should then be filed with the state by fax to 800-403-0864 or delivered by mail or in person to your local county office.

You can check the status of your application online or by calling 1-800-403-0864. You will need to have your case number to check the status of your application.

Register and sign in. Create a free account, set a strong password, and proceed with email verification to start working on your forms. Add a document. Click on New Document and choose the file importing option: upload Snap verification documents indiana from your device, the cloud, or a secure URL.

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232