Free 49049.FH11 - Indiana

IMPACT RESPONSIBILITIES, SANCTIONS, AND RIGHTS VOLUNTARY CLIENTS AND TANF MINORS
State Form 49049 (R2 / 12-07) / IMP 0032

The goal of the IMPACT program is full-time employment with benefits to reduce or eliminate your need for assistance. The following responsibilities must be met in order for IMPACT to assist you in meeting the goal. It is YOUR responsibility to: 1. Keep scheduled appointments with your Impact Case Manager; 2. Keep scheduled appointments at other places when you have been sent by your Impact Case Manager. 3. Participate fully in all employment and training activities outlined in your plan for employment and accept and retain employment; and 4. Accept suitable child care, transportation and other supportive services offered in order to participate in an employment and training program. We encourage you to fully cooperate with IMPACT by attending all scheduled appointments and assignments. When you anticipate problems which may make you unable to fully meet the above responsibilities, you should discuss the problems with your Impact Case Manager. The Impact Case Manager may help you to develop action steps that may allow you to meet your IMPACT responsibilities. If the above responsibilities are not met and you do not have good cause, you may be sanctioned or penalized. An IMPACT sanction will result in the loss of your eligibility and loss of Temporary Assistance to Needy Families (TANF) as outlined below. If you receive TANF, the following sanction applies if you fail to meet your responsibilities without good cause: Failure to meet IMPACT requirements without good cause will result in a loss of Medicaid benefits for the non-complying member and the entire assistance group will lose TANF benefits. If you are a volunteer for Food Stamps IMPACT, the following penalty may apply if you fail to meet your responsibilities without good cause: Loss of all IMPACT services. Should you be notified of an IMPACT sanction or penalty, contact your Impact Case Manager to discuss how to end a TANF IMPACT sanction or avoid a Food Stamp IMPACT penalty by meeting your responsibilities. You have the right to: 1. Quit the IMPACT program without losing Food Stamp benefits if you are a volunteer for Food Stamp IMPACT. 2. Fair and equal treatment in the assignment of employment and training activities; 3. File a written complaint if you think you have been discriminated against; 4. Work out differences with the Impact Case Manager through conciliation; and 5. Request a hearing if you are no longer allowed to participate in IMPACT, and you do not agree with our determination that you failed without good cause to meet a responsibility. I understand the above responsibilities, sanctions and rights:
Signature of client Date (month, day, year)

Name of Impact Case Manager (print)

Telephone number of Impact Case Manager

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DISTRIBUTION: White - Client; Canary - IMPACT case file