FSSA Document Center *FSS407AE00121YU2SE8*
PO Box 1810
Marion, IN 46952
*FSS407AE00121YU2SE8*
015875
Kelcie N Grigsby
228 S 6th St
208
Terre Haute, IN 47807-4242
Page 1 of 1 G0000001000004015875000001
*FSS401AE00121YU2SE2*
SNAP Interim Contact Payee Name : Kelcie N Grigsby
Part of State Form 53825 (R8 / 12-21) / DFR 2310 / IEDSS
Case Number : 6007126275
AG Number : 22900269
Indiana Family and Social Services Administration
PO Box 1810 Program : SNAP
Marion, IN 46952
Telephone/Fax: 1-800-403-0864
Mailing Date : SEPTEMBER 15, 2023
Kelcie N Grigsby
228 S 6th St
208
Terre Haute, IN 47807-4242
SNAP Interim Contact
It is time for an Interim review of your Supplemental Nutrition Assistance Program (SNAP) eligibility.
To determine if your household is eligible to continue receiving SNAP benefits, we need to know if there have been changes in
your household situation. There is no need to conduct an interview. You need to complete and return the enclosed form with
verification of new information no later than the Deadline Date listed on the form.
∑ Enclosed is the SNAP Interim Contact Form that we need you to complete, sign and return.
∑ We will use the information you provide on the form to see if your household is still eligible for SNAP benefits.
∑ It is VERY important that you return this form with verification of new information by the Deadline Date OCTOBER 02, 2023.
If you do not return the form and verification of new information, your SNAP benefits will end.
After you send the form to us, we will review it.
∑ If we have questions about the information you provided, we will contact you.
∑ If there are changes to your benefits, you will receive a notice telling you how those changes affect your SNAP benefits.
If you answer Yes to any of the questions on the form:
∑ We will need verification of the new information.
∑ If you have the verification when you complete the form, send copies of the verification with your completed
Interim Contact Form. This will help us process your eligibility faster.
∑ Examples of verification we need are:
o For jobs: pay stubs for the last thirty (30) days.
o For unearned income: award letter with current amount.
o For new vehicles: vehicle registration.
o For resources: most recent bank statement.
If you do not send the verification with the form, we will send you a Pending Notice listing the verification(s) we need from you.
If you do not send this form or any needed information by the Deadline Date, we cannot determine SNAP eligibility for the
household. SNAP benefits will end.
Please mail the completed form to:
FSSA Document Center
P.O. Box 1810
Marion, IN 46952
Page 1 of 2 00000002000004015875000002
*FSS401AE00221YU2SE1*
Or fax to 1-800-403-0864.
Or drop it off at a local FSSA/Division of Family Resources office.
If you have questions, please call the FSSA Call Center at 1-800-403-0864 Monday through Friday
between 8:00 AM and 4:30 PM.
Thank you,
Indiana Family and Social Service Administration
Page 2 of 2
*FSS334BE00121YU2SEC*
SNAP INTERIM CONTACT
State Form 53825 (R8 / 12-21) / DFR 2310 / IEDSS
Mail or Fax completed form to:
FSSA Document Center
Case Number: 6007126275
PO Box 1810
Payee Name: Kelcie N Grigsby Marion, IN 46952
or
The DEADLINE for returning this form is: OCTOBER 02, 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.
Page 1 of 2 00000003000004015875000003
*FSS334BE00221YU2SEB*
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.
Signature: __________________________________ Date: (month,day,year)________________________________
Page 2 of 2
*FSS401AE00121YU2SE2*
Verifying Information for Your SNAP Interim Contact Payee Name : Kelcie N Grigsby
Part of State Form 53825 (R8 / 12-21) / DFR 2310 / IEDSS
Case Number : 6007126275
Indiana Family and Social Services Administration
PO Box 1810 AG Number : 22900269
Marion, IN 46952
Telephone/Fax: 1-800-403-0864 Program : SNAP
Mailing Date : SEPTEMBER 15, 2023
Verifying Information for Your SNAP Interim Contact
If you answer 'YES' to any questions when you complete your SNAP Interim Contact Form, we will need verification of the new
information about your household.
Listed below are verifications we will need for the different types of changes included on the Interim Contact Form. If you have
verification(s) of the change(s) you report on the form, send them with the form to help us process your eligibility faster.
IMPORTANT: Write your Full Name and Case Number or Social Security Number on all verifications you send.
If we do not receive needed verification(s) with your form, we will send you a Pending Notice to let you know what information
needs to be verified. If the needed verification(s) are not provided, your SNAP benefits will end.
New Person in Household Income from Work
Social Security Number or proof of application Earnings: pay stubs, copy of paychecks, a statement
for Social Security Number. from employer, or self-employment records.
If Person is not a US Citizen: Employment Termination: a statement from
Provide their Alien Registration card, permanent the person's last employer giving dates of employment
resident card, or other documentation from the and reason for termination.
US Bureau for Citizenship and Immigration Services.
Other Income
Shelter Expenses Child Support, Social Security, VA, SSI, Workers'
Housing Costs: Rent or mortgage receipts, Compensation, disability, sick, unemployment or other
cancelled checks or check stubs, statement from benefits: award letter, notice, court order, or other proof of
landlord or lender with their name, address, payment from the source of income.
and telephone number.
Loans, gifts, or contributions: loan agreement; or statement
Utilities: Most recent utility bills showing your from person providing the money that includes the person's name,
name and current address. address, phone number, signature, and date.
Child Support Paid Resources
Divorce Decree; court order; or copy of county Money in the bank or credit union: current statements.
clerk record, showing who pays, the amounts paid,
and the dates paid. Stocks, bonds, trusts and annuities: trust agreement, annuity
contract, stock certificate, bond instrument, current statements, etc.
Vehicles: registration, or title or statement of value from licensed car
dealer for all cars, vans, trucks, etc.
Real estate, oil, gas, and mineral rights: current tax statements,
court orders, deeds, royalty statements, legal documents, etc.
Your verifications may be returned by:
∑ Mailing copies to: FSSA Document Center, PO Box 1810, Marion, IN 46952, or
∑ Faxing to: 1-800-403-0864, or
∑ Dropping off at a local FSSA/Division of Family Resource office.
Page 1 of 1 00000004000004015875000004