Get In State Form 53460 2017-2025

This guide provides clear, step-by-step instructions for completing the IN State Form 53460 online. Whether you are authorizing someone to assist you with benefits applications or ongoing representation, following these steps will ensure a smooth process.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, read the instructions carefully. Indicate whether you want to authorize someone to act on your behalf for applying for benefits. Select the function(s) that the representative will perform. You can choose multiple representatives and functions, but complete one form for each representative.
3. Proceed to Section 2. Clearly print the name of your representative. Then, check the box that best describes your representative's relationship to you, selecting one of the options: Attorney, Eligibility Assistance Company, Friend, Family, Institution of Residence, Waiver Case Manager, or Other.
4. Provide the mailing address of the authorized representative, including the number and street, city, state, and ZIP code.
5. Select the function(s) the authorized representative will perform regarding your benefits, such as applying for benefits, ongoing assistance, or EBT functions. Be sure to check the boxes that correspond to the representative's responsibilities.
6. If an EBT function is selected, enter the authorized representative's date of birth and social security number in the specified fields.
7. Both you and your representative must sign and date the form in the designated area. Ensure that you provide your telephone number for contact purposes.
8. In Section 3, verify that you authorize the representative to act on your behalf in the reviewed functions. If applicable, ensure additional documentation is added if you are unable to sign due to medical reasons.
9. Provide your name, signature, date, case number (if applicable), date of birth, and social security number in the respective fields.
10. Once all sections are complete, save your changes, download the form, print it if required, or share it with the appropriate parties.

Start completing your IN State Form 53460 online today!