Get State Form 53391 (r4 / 9-18)

Filling out the State Form 53391 is a key step for those seeking to operate a personal services agency in Indiana. This guide provides clear instructions on how to complete the form online, ensuring that your application is processed smoothly and efficiently.

Follow the steps to fill out the State Form 53391 online.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. In Section I, indicate the type of application you are submitting by checking the appropriate box for either a change of ownership or a new agency.
3. Complete Section II with identifying information for the personal services agency. Provide the agency name, physical address, contact details, and office hours.
4. In Section III, provide staffing details. Include names and contact information for the manager and any alternate managers.
5. In Section IV, disclose the ownership and controlling interest of the agency. List names and addresses of individuals with ownership interest, along with their percentages.
6. Section V should only be filled if there is a change of ownership. Indicate the type of agreement if applicable.
7. Certification in Section VI must be completed. Type or print the name, sign the application, and date it.
8. Compile any required documentation, including IRS and Secretary of State documents, as mentioned in Sections VII and VIIII.
9. Finally, review all information for accuracy, save your changes, and prepare to submit the application along with the non-refundable fee.

Begin the process of submitting your application online today!