Free 18438.pdf - Indiana

RECOMMENDATION OF COUNTY OFFICE - Assistance to Residents in County Homes / Room and Board Assistance
State Form 18438 (R2 / 7-97) / BAIS 0052 Approved by State Board of Accounts, 1982 CONFIDENTIAL per IC 12-10-6 *Request for Social Security number is mandatory per IC 4-1-8-1; 12-10-6

STATE USE ONLY
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COUNTY OFFICE OF FAMILY AND CHILDREN INSTRUCTIONS for County Office of Family and Children: Complete three (3) copies. Send the original and one (1) copy I recommend the approval of the actions, amounts and effective dates on the to the FSSA Claims Department for receipt by the twentieth (20th) of the month. Retain one (1) copy for County records. cases listed below on pages numbered _________ thru ________ inclusive.
County Code number County record number Program Signature of Director Date signed (mo., day, yr.)

ARCH LINE (1) CASE NUMBER
*SOCIAL SECURITY NO.

AWD CHG DISC DEN SAME

(2) NAME OF APPLICANT OR RECIPIENT (Name and mailing address of legal guardian, if applicable)

RBA (3)

(4)

(5) EFFECTIVE DATE

NAME AND ADDRESS OF FACILITY

(6) AMT FOR . PERSONAL NEEDS

(7) NARRATIVE REASONS, EXPLANATION, REMARKS

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2

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LINE

*SOCIAL SECURITY NO.

NAME AND ADDRESS OF FACILITY

1

2

3

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5

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9

10

AWD CHG DISC DEN SAME

(1) CASE NUMBER

(2) NAME OF APPLICANT OR RECIPIENT (Name and mailing address of legal guardian, if applicable)

(3)

(4)

(5) EFFECTIVE DATE

(6) AMT. FOR PERSONAL NEEDS

(7) NARRATIVE REASONS, EXPLANATION, REMARKS