Free 49029.FH11 - Indiana

IMPACT RESPONSIBILITIES, SANCTIONS, AND RIGHTS MANDATORY ADULT CLIENTS
State Form 49029 (R2 / 12-07) / IMP 0033

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 who will help you develop a self-sufficiency plan that will 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. An IMPACT sanction will result in the loss of your eligibility and loss of Temporary Assistance to Needy Families (TANF), Medicaid, and/or Food Stamp benefits as outlined below. When an adult is sanctioned due to not meeting the above requirements, the months the sanction is served will count toward the TANF assistance time limits. If you receive TANF, the following sanctions apply 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 member of a household receiving Food Stamps, the following sanctions may apply if you fail to meet your responsibilities without good cause: The first time: Loss of your Food Stamp eligibility for 2 months or until you meet your IMPACT responsibilities, whichever is longer. The second time: Loss of your Food Stamp eligibility for 6 months or until you meet your IMPACT responsibilities, whichever is longer. The third time: Loss of your Food Stamp eligibility for 36 months or until you meet your IMPACT responsibilities, whichever is longer.

Should you be notified of an IMPACT sanction, contact your Impact Case Manager to discuss how to end a TANF, Medicaid and/or Food Stamp IMPACT sanction or avoid a Food Stamp sanction by meeting your responsibilities. You have the right to: 1. Fair and equal treatment in the assignment of employment and training activities; 2. File a written complaint if you think you have been discriminated against; 3. Work out differences with your the Impact Case Manager through conciliation, and 4. Request a hearing if your household's TANF, Medicaid and /or Food Stamps benefits were reduced or denied and you do not agree with our determination that you must participate in IMPACT or 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