FSSA Document Center *FSS407AE0012QELPWD1*
PO Box 1810
Marion, IN 46952
*FSS407AE0012QELPWD1*
022487
Melissa L Garcia
1246 W 32nd St
Indianapolis, IN 46208-4537
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*FSS411AE0012QELPWDC*
PENDING VERIFICATIONS FOR Payee Name: Melissa L Garcia
APPLICANTS / RECIPIENTS
Case Number: 6008878611
State Form 56192 (R18 / 5-24) / DFR 2032 / IEDSS
Mailing Date: AUGUST 02, 2024
YOUR DEADLINE FOR SUBMITTING THIS INFORMATION IS:
SNAP HEALTH COVERAGE CASH ASSISTANCE
AUGUST 15, 2024
PENDING VERIFICATIONS
IMPORTANT - This request for additional information is for Supplemental Nutrition Assistance Program(SNAP), Cash
Assistance or Health Coverage benefits you have applied for or are receiving. This application will be denied or current
benefits discontinued unless a response is received by the deadline(s) specified above.
1. Please fax (faster than mail) or mail copies of the items requested for the individual(s) named in the table below to Family
and Social Services Administration (FSSA) or your benefits will be denied or discontinued.
2. If you do not have the exact papers listed below, you may send/bring in others that provide the same information.
3. If you need help getting the information requested, contact FSSA at 1-800-403-0864.
4. Write the Head of Household name and Case number on each item you fax or mail.
5. MAIL OR FAX THE DOCUMENT COVER SHEET AND THE OTHER ITEMS NEEDED TO:
FSSA Document Center
PO Box 1810
Marion, Indiana 46952
Fax: 1-888-436-9199
6. Please note: if you sent the requested information since the mailing date of this notice, you do not need to send
the documents again.
INCOME
Income for HIP and Hoosier Healthwise
In order to determine eligibility, Income must be verified for the individual(s) listed below. If income was the same in the
three (3) months before you applied, you do not have to supply additional proof for those months.
Name Program Health Coverage Type Employer Name Additional Comment
Recipient
Melissa L Garcia Health Melissa L Garcia Wages VISITING Provide all gross Income
Coverage ANGELS verification for last 30
days
Melissa L Garcia Health Isaac A Garcia Wages VISITING Provide all gross Income
Coverage ANGELS verification for last 30
days
Example of Proofs:
Pay stubs, employer's statement of earnings including hours worked in a pay period and amount earned per hour and when
paid. Provide the past twelve (12) months of the individual(s) self-employment income.
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*FSS408AE0012QELPWDH*
DOCUMENT COVER SHEET
State Form 53677 (R2 / 4-24) / DFR 1010 / IEDSS
Case Information
Client Name: Melissa L Garcia Address: 1246 W 32nd St
Indianapolis, IN 46208-4537
Case Number: 6008878611
Instructions
∑ This form helps you send documents back to us for the case shared above in Case Information. Return this
form with your documents to assist us in processing your documents faster, using any of the following
methods:
∑ Electronically: For fastest processing, you can upload documents online using the FSSA Benefits Portal
at [Link]. You will need to create an account if you have not already done so.
∑ Mail: You can mail the documents to:
FSSA Document Center
PO Box 1810
Marion, IN 46952
∑ Fax: You can fax the documents to 1-888-436-9199.
∑ If you are unable to send all documents together, you may copy this form for sending other documents to the case shared
above in Case Information.
∑ If you have questions, please call us toll-free at 1-800-403-0864 between 8:00 AM and 4:30 PM, local time, Monday
through Friday.
Comments or Documents Included
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