Free 48895.FH11 - Indiana

Date

INITIAL APPOINTMENT FOR IMPACT
State Form 48895 (10-98) / IMP 0030 Case number Social Security number

The information contained on this form is CONFIDENTIAL according to 470 IAC 1-2-7, 470 IAC 1-3-1, and 470 IAC 6-1-1.

Dear _____________________________________________: You have been identified as an individual who is required / has volunteered to participate in IMPACT, an employment and
(Circle appropriate one)

training program. An IMPACT appointment has been scheduled for you on ____________________________________ ,
Day

____________________________________________ at ______________________________ .
Date Time

This appointment will be held at the following location:

The following activities will be done at this appointment: 1. A brief presentation of the IMPACT requirements and opportunities that can help you become self-sufficient. 2. An assessment of your employability. Please have information concerning your education, training, and work history at this appointment. 3. A plan for employment and self-sufficiency will be developed. 4. A discussion of your IMPACT responsibilities and participation. 5. Other: ___________________________________________________________________________________ You must come to this meeting or the household could lose TANF (Temporary Assistance for Needy Families), Medicaid and / or Food Stamp benefits. If you are unable to attend this appointment, or if you need help with child care or transportation, please contact the IMPACT worker at the telephone number listed below prior to the appointment to discuss the reason. Sincerely,

Telephone #:
DISTRIBUTION: White - Client; Canary - Case File

IMPACT Worker