Free 47073.FH11 - Indiana

INDIANA FAMILY & SOCIAL SERVICES ADMINISTRATION PARTNERSHIP FOR PERSONAL RESPONSIBILITY

PERSONAL RESPONSIBILITY AGREEMENT
I understand that public assistance is not intended to be a way of life, but is intended as temporary assistance to help me achieve the capability for self support and personal independence. Although the agency will assist me in achieving the goal of self-sufficiency, I understand that it is my responsibility to secure and retain employment, and all other applicable sources of income, for the support of myself and my dependent children. In return for receiving Temporary Assistance for Needy Families (TANF), I accept personal responsibility for myself and my dependent children and I agree to the following terms: If I am a mandatory participant in the Indiana Manpower Placement and Comprehensive Training (IMPACT) program, TANF cash benefits for myself will be limited to twenty-four (24) months. I will not receive any additional cash benefits for children who are born more than ten (10) months after the date that I am authorized to receive TANF benefits. I will ensure that my children receive their age appropriate immunizations. I will ensure that my school age children regularly attend school and that they have no more than three (3) unexcused absences during the semester or grading period. I will raise my children in a safe, secure home which is free of domestic violence or incidents of child abuse or neglect. I will not use illegal drugs or other substances that would interfere with my ability to be self-sufficient. I will participate in all employment and training activities to which I am assigned. I will not voluntarily quit a job of twenty (20) hours or more per week or voluntarily reduce my hours of employment. If I am a minor parent, I will reside with an adult who is related to me as a parent, stepparent, or grandparent; or an adult who is my legal guardian. If I commit an intentional program violation or if I am convicted of committing fraud related to establishing or maintaining eligibility or increasing benefits under TANF, I will be penalized under the state's TANF fraud control program. I will cooperate in developing a self-sufficiency plan and will comply with the requirements specified in the plan. If I do not comply with the provisions of this agreement sanctions may be imposed, including the loss of cash benefits. If I do not comply with the requirements of the IMPACT program, I may lose cash benefits and Hoosier Healthwise. I understand that my TANF benefits may be reduced if I fail or refuse to sign this agreement. I also understand that in some circumstances the agency may determine that I had good cause for not complying with the terms of this agreement or the requirements of the IMPACT program and in certain circumstances I may be granted an extension or exemption of a specific program requirement.

SIGNED

Parent / Caretaker Relative

Date (month, day, year) State Form 47073 (R4 / 6-09) / FI 0010