FSSA Application Document

Topics: Social Security number, Social Security Administration, Social Security Pages: 28 (6983 words) Published: September 21, 2012
FSSA Document Center P.O. Box 1810 Marion IN 46952


Santoshi R Naidu 2612 Eastgate Lane Apt: Apt G Bloomington, IN 47408

State Form 53678 (R2 / 1-11) / DFR 1011


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Please fill out and submit this form when you send copies of documents that we have asked you to provide. A list of the documents to provide is in the Information to Get You Started instructions included with your application. When you have filled out this form, place it on top of the copies of your documents and mail or fax it and your copies to: Mailing Address: FSSA Document Center PO Box 1810 Marion, Indiana 46952 Fax Number: 1-800-403-0864

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To fill out the form, please complete the Documents Included section below using a blue or black ink pen. Place an X in the box next to each document that you are sending us. Example: X Utility Bill If a document that you are sending us is not listed, then place an X in the box next to ‘Other(s)’ and write the name of the document(s) on the line provided. Please send copies of the documents instead of originals. Write your name and Social Security Number on each item you fax or mail. This form should be used to provide information for your household only. You may copy this form before filling it out and save it to use later if you cannot send in all of the requested documents now. If you have questions, please call us toll-free at (1-800-403-0864) between 8:00 AM and 4:30 PM Monday through Friday. Identity Money Received (con’t) Resources (con’t) Child Care / Child Support Expenses

□ Driver’s License □ State Photo ID Card □ Student Photo ID Social Security Number

□ Disability Payments □ Employer Statement □ Employer Statement of Termination

□ Stock / Bond Statement or

□ Trust Statement □ Vehicle Registration

□ County Clerk Record for
Child Support

□ Proof of Child Support You

□ Social Security Card □ Proof of Application for
Social Security Card

US Citizenship / Immigration Status

□ Alien Registration Card □ Baptismal Certificate □ Birth Certificate □ Bureau for Citizenship & Immigration Svcs. Document

□ Pay Stubs □ Pension Statements / Stubs □ Railroad Retirement Benefits □ Self Employment Records □ Sick Benefits □ Social Security / SSI Award Letter

□ Receipt / Copy of Check for
Child Care that You Pay

□ Insurance Card □ Life / Burial / Health
Insurance Policy

□ Statement from Child Care

□ Statement from Insurance


□ Statement of Loan, Gift or


□ Hospital Birth Certificate □ Passport □ Permanent Resident Card Money Received / Income

□ Unemployment Benefits □ Veteran’s Benefits □ Worker’s Compensation Resources

□ Cancelled Rent Check □ Homeowner’s Insurance

□ Medical Bill / Receipt □ Medical Statement □ Medical Statement of Pregnancy / Due Date

□ Prescription Receipt or

□ Lease Agreement □ Proof of Energy Assistance


□ Child Support – Proof of
Payment Received

□ Annuity Contract □ Bank/ Credit Union Statement □ Real Estate, Oil, Gas or Mineral Rights Deed/Document

□ Proof of Public Housing

□ Copy of Paychecks

□ Statement of Vehicle Value
from Licensed dealer

□ Property Tax Statement □ Rent Receipt □ Landlord or Mortgage Lender Statement

□ Divorce Decree □ Guardianship Order □ Marriage Certificate □ Paternity record □ Power of Attorney

□ Utility Bill

Other Documents

□ Other(s): _____________________________________________________________________________________________________________________



____________________________________________________________ Thank you for applying using the online application system of the Family and Social Services Administration (FSSA). Please review the...
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