Free 48830.FH11 - Indiana

IMPACT MEMORANDUM
State Form 48830 (R / 9-05) / IMP 0029

The request for your Social Security number is MANDATORY for completing this form, according to IC 4-1-8, FS Act of 1977, Sec. 16-E, SSA 4(a)(2). The information contained on this form is CONFIDENTIAL, according to 470 IAC 1-2-7; IAC 1-3-1 and 470 IAC 6-1-1.

TO:

RE:

County Case number

Social Security number

FROM:

Success story Employment information Status change (TANF/UP/FS/Discontinued) Participation/Attendance Name/Address/Telephone number change Other:

Schedule change Client exit Client sanctioned

DATE:
Effective date (month, day, year) Comments: Request response Yes No

DISTRIBUTION: White - Provider; Canary - COFR; Pink - Other