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FSSA Document Center P.O. Box 1810 Marion IN 46952 *DFRMLAE01007AH3P4* *DFRMLAE01007AH3P4* Santoshi R Naidu 2612 Eastgate Lane Apt: Apt G Bloomington, IN 47408 APPLICATION DOCUMENT COVER SHEET State Form 53678 (R2 / 1-11) / DFR 1011 *DFRASAE01007AH3P3* Instructions    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  …show more content…
Please note that: You should provide copies of documents that are required for the programs you are applying for and provide copies of documents for each person who is applying for assistance. This information may be necessary for others who live in your home, even if they are not applying for assistance. See the list below to determine what you need to send. If you have questions or need help getting any of these documents, please go to our Web site at www.in.gov/fssa/apply or call our toll-free number, 1-800-403-0864 To provide proof of… Your Identity Social Security Numbers (SSN) US Citizenship What you can send us…. Valid driver’s license or state or student photo ID card. If you have someone acting on your behalf, that person will need to provide proof of his or her identity and proof of your identity. When you do not have a SSN for a person you are applying for, you will need proof that you have applied for one. Birth certificate, hospital certificate, or baptismal certificate or other acceptable proof of birth. In some cases, when one of these documents is not available you may provide a signed statement from another person who is a US citizen, stating that the person you are applying for is a US citizen. Alien registration card, permanent resident card, or other documentation from the Bureau for Citizenship and
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