Free 47991.FH11 - Indiana

APPLICATION FOR ASSISTANCE - PART 3 Client Certification And Assignment
State Form 47991 (R4 / 6-05) / FI 2403

ASSIGNMENT OF RIGHTS TO MEDICAL SUPPORT AND PAYMENT FOR MEDICAL CARE: In return for medical assistance provided under this application, I hereby assign my rights to medical support and payments for medical care which I have on behalf of myself or any other person under this application, from any third parties, to the State of Indiana to reimburse it for assistance provided. This assignment is required under 42 USC 1396k. I agree to cooperate, as required, in obtaining any such rights to payment or medical care which I have on behalf of myself or any other person under this application. I understand that failure to cooperate without establishing good cause shall result in ineligibility for medical assistance. I have received a "Notice Regarding Rights and Responsibilities" which explains the cooperation requirements. This assignment becomes effective on the first day of medical assistance coverage granted to me or any other person under this application. It remains in effect until the State has been reimbursed for all medical services provided to me or any other person under this application.
Signature Date signed (month, day, year)

FOOD STAMP REGISTRATION: I understand that to be eligible for Food Stamps, all Assistance Group members age 16 through 59 who are not exempt, must register for work and perform specific activities. By signing this document, I am registering all persons required to be registered. When my Assistance Group is approved, I will receive a list of the persons registered for work and referred to IMPACT and a statement of their rights and responsibilities. ASSIGNMENT OF RIGHTS TO CHILD SUPPORT: For public assistance received and to be received, I the undersigned, understand that I have assigned and transferred to the Division of Family Resources, all support rights (accrued, pending and continuing) which I have against the named absent parent(s). This assignment is subject to 42 USC SECTION 602(a)(26) as amended. This assignment shall terminate with respect to current support rights upon termination of eligibility for Temporary Assistance For Needy Families (TANF) assistance, but current support will continue to be collected and distributed to the recipient after date of termination of TANF, unless the recipient notifies the Child Support Bureau in writing that enforcement services should be discontinued. This assignment shall not terminate with respect to support rights (arrearages and/or delinquencies as of the date of termination of eligibility for TANF assistance) unless and until the past public assistance received at any time by the above recipient for themselves and/or these or any other child(ren) has been fully repaid. After termination of TANF, if the obligor owes arrearages to the State, owes arrearages accrued after termination to the recipient, and the recipient discontinues enforcement services, all amounts collected in excess of current support will be first applied to pay off the amount owed the State. If enforcement services continue after termination of TANF, all collections in excess of current support will first be applied to arrearages accrued after termination and paid to the recipient. Pursuant to the cooperation notice I have received, I agree to cooperate in getting the absent parent to pay support. I understand that failure to cooperate may result in termination of financial assistance for myself. I certify under penalty of perjury that the following are true: I have read (or had read to me) the "Notice Regarding Rights and Responsibilities" and understand what it states. I have reviewed all information provided by me and entered by the interviewer concerning my Assistance Group(s). I understand that I am not attesting to documentation of verifications and calculations entered by the interviewer concerning my Assistance Group(s). I understand that any individual who is fleeing to avoid felony prosecution, or confinement after felony conviction, or is in violation of probation / parole resulting from a felony conviction will be ineligible to receive Food Stamps and Temporary Assistance for Needy Families (TANF). I understand that any individual who has been convicted under federal or state law of a felony which has as an element of the offense, the possession, use, or distribution of a controlled substance will be ineligible to receive Food Stamps and TANF. All information I have provided, which has been entered by the interviewer, is complete and correct to the best of my knowledge and belief, including the information given about the citizenship or immigration status of each applicant.
Signature of Interviewee Date signed (month, day, year)

Signature of Witness (if signed with an "X")

Date signed (month, day, year)

Signature of Interviewer

Date signed (month, day, year)