Free 48259.pdf - Indiana

APPLICATION FOR UNDUE HARDSHIP WAIVER
State Form 48259 (7-97) / OMPP 0003

The information contained on this form is CONFIDENTIAL according to I.C. 12-15-27.

* The request for your Social Security number is VOLUNTARY and you are not required to supply it according to 42 CFR 435.910.
1. Name of applicant 2. Telephone number ( 3. Street address 6. ZIP code )

4. City

5. State

7. County

8. Social Security number *

9. Name of the deceased

10. Deceased's date of birth 12. Deceased's medicaid recipient identification number (if known)

11. Deceased's Social Security number *

13. What is your relationship to the deceased?

Spouse Child

Parent Grandparent

Sister Brother

Grandchild Great-grandchild

Other (please specify relationship)
14. Please indicate which of the following conditions is the basis for your claim of undue hardship:

Enforcement of the state's claim will cause the applicant to become eligible for public assisstance; Enforcement of the state's claim will cause the applicant to remain dependent on public assistance; Enforcement of the state's claim will result in the complete loss of the applicant's sole source of income; Other compelling circumstances, as described in #20 below.
15. Do you currently receive benefits under any of the following programs? (check all that apply)

Temporary Assistance for Needy Families Medicaid Food Stamps Supplemental Security Income (SSI)
16. If you receive benefits under any of the above programs, please indicate your Recipient Identification Number:

17. Will enforcement of the state's claim result in a reduction in your current income? If your answer is yes, explain below.

Yes

No

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18. Please list all sources of income and the amounts you currently receive from each source. Indicate the frequency (weekly, bi-weekly, monthly, quarterly, annually) for each reported amount. Please attach supporting documentation (pay stubs, bank statements, dividend statements etc.)

SOURCE

AMOUNT per per per per per

19. Please list the property that you expect to receive from the deceased's estate. Include real estate, cash, bank accounts, stocks, bonds, and other tangible property. You need not list personal effects or keepsakes.

20. Please describe any other relevant factors or circumstances that you think should be considered in reviewing this request for a waiver of the state's claim. (Attach additional sheets if necessary.)

Please attach supporting documentation to support your claim of undue hardship. I affirm that the foregoing information and any attachments are true and accurate to the best of my knowledge.
Signature of applicant Date (month, day, year)

Submit completed form and supporting documentation to:

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