Org Dev Essay
Santoshi R Naidu 2612 Eastgate Lane Apt: Apt G Bloomington, IN 47408
APPLICATION DOCUMENT COVER SHEET
State Form 53678 (R2 / 1-11) / DFR 1011
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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We will schedule an interview and mail an appointment letter to you. The letter will tell you the time and if it is a telephone or inperson interview. If it is an in-person interview, the letter will include the office location where the interview is scheduled. If you cannot keep the interview appointment, please call us at 1-800-403-0864 to reschedule before the appointment time.
What additional information do you need to send us?
Please send copies of any of the documents listed below as proof of the information on your application. Mail or fax these copies as soon as they are available. You may also submit copies at your local Division of Family Resources Office. Sending us this information will help us process your application much faster. If you have designated an Authorized Representative, please complete and sign the Authorized Representative form included in this packet. We have enclosed a Document Cover Sheet for you to put on top of the copies you mail to us. It is important that you include a copy of the Document Cover Sheet with any document copies you send; it will help us process your documents faster.