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SNAP INTERIM CONTACT

State Form 53825 (R8 / 12-21) / DFR 2310 / IEDSS
Mail or Fax completed form to:

FSSA Document Center
Case Number: 6006856655
PO Box 1810
Payee Name: Shareeda Mcatee Marion, IN 46952
or
The DEADLINE for returning this form is: JUNE 01, 2023
Fax: 1-800-403-0864
To check your household’s eligibility for SNAP, we need to know if there have been any changes in your
household’s situation. Complete, sign and return this form to us.
We will use the information you give us to check SNAP eligibility. When you return your completed form include
copies of verification of new information you have available (see enclosed letter for more information).
If you have questions, please call the FSSA Call Center at 1-800-403-0864. If you need more room to answer the
questions, please attach a separate page and write your case number and name at the top of the page.
1. Has your address or telephone number changed? Yes No If No, you may skip to question 2.
If Yes, complete the following information and provide proof of your new address and shelter expenses.
If you do not provide proof of your expenses, you will not receive a shelter deduction in your budget.
Home Address
_______________________________________________________________________________________________
Street City State Zip code Home Telephone Number
Mailing Address
_______________________________________________________________________________________________
PO Box / Street City State Zip code Other Telephone Number
If your address has changed, answer the following questions:

Enter the amount you are charged each month for your rent or mortgage: $_____________________________
Do you pay to heat or cool your home? Yes No

If no, check the utilities you are responsible for paying: Electric Water Sewer Trash Telephone
2. Have the persons living in your home changed? Yes No
3. Has the income from work changed for any member of your household? This includes changes in
employer, hourly rate, salary or changes in full/part-time status. Yes No
4. Has there been a change of unearned income for any member? This includes a change in the income
source or a change of more than $125 in the monthly amount. Yes No
If Yes, list the type of income and monthly amount in #10 below. Examples of unearned income include payments
from child support, Unemployment Benefits, Workman’s Compensation Benefits, Social Security, and SSI Benefits.
5. Has any member had a change in his/her legal obligation to pay child support? Yes No
If Yes, explain the change in #10 below.
'
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SNAP INTERIM CONTACT (continued)

State Form 53825 (R8 / 12-21) / DFR 2310 / IEDSS
6. In the past six (6) months have the vehicles owned or being bought by any member of your
household changed? Yes No
7. Are the total resources owned by you or any member of your household (such as checking,
savings, cash, or other accounts or assets) $5,000 or more? Yes No
8. If anyone in the household has been identified as an ABAWD (able bodied adult without
dependents), they must report if their hours of employment fall below eighty (80) per month. Is
there an ABAWD in the household whose has decreased work hours to less than eighty (80) per
month? Yes No
9. You are required to report when you receive substantial lottery or gambling winnings.
Substantial winnings would be equal to or greater than $3,750 before taxes or other amounts
are withheld. Have you or any member of your household received lottery or gambling
winnings of $3,750 or more? Yes No
10. If you checked Yes to any of the questions above, please explain here.
By signing this form, I understand and agree that:
My answers on this form will affect my benefits. This information may cause my benefits to increase,
decrease or stop. I will get a notice explaining how my answers on this form will affect my benefits and
how to ask for a hearing.
Every person who receives SNAP benefits must follow these rules:
DO NOT give false information to get or continue to get SNAP benefits

DO NOT trade or sell SNAP benefits or Hoosier Works cards
DO NOT alter documents to get more SNAP benefits than you are entitled to receive
DO NOT use SNAP benefits to buy ineligible items, such as alcoholic beverages and tobacco
DO NOT use someone else’s SNAP benefits or Hoosier Works card for your personal gain
If you break the above rules on purpose, you can be barred from the SNAP Program for twelve (12)
months if it is your first violation, twenty-four (24) months for a second violation and permanently for a
third violation.
Under penalty of perjury, all the information I have provided is complete and correct to the best of my
knowledge.
6/1/2023
Signature: __________________________________ Date: (month,day,year)________________________________
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FSS334BE001BAZSCUL0

SNAP INTERIM CONTACT

Mail or Fax completed form to:

If your address has changed, answer the following questions:

Do you pay to heat or cool your home? Yes No

2. Have the persons living in your home changed? Yes No

SNAP INTERIM CONTACT (continued)

By signing this form, I understand and agree that:

DO NOT give false information to get or continue to get SNAP benefits

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