FSSA Document Center

PO Box ****

Marion, IN ****2

Zachery S Barnes

**** * ******** **

Fort Wayne, IN 46807-2027

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006363

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Page 1 of 1 G0000001000002006363000001

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Proof Of Eligibility

State Form 53549 (R2 / 6-20) FI 2430 / IEDSS

Mailing Date: JANUARY 20, 2024

Agency Information

Family and Social Services Administration Document Center PO Box 1810

Marion, Indiana 46952

Telephone: 1-800-***-****

Case Information

Full Name: Zachery S Barnes Date of Birth: 08/13/1984 Case Number: 601******* Mailing Address: 3735 S Harrison St Fort Wayne IN 46807

Home Address: 3735 S Harrison St

Fort Wayne IN 46807-2027

Scheduled Appointment

Appointment Type Appointment Date Scheduled Time Office Location Expedited SNAP without

MA

JANUARY 30, 2024 08:00 AM 201 E Rudisill Blvd Ste 302 Fort Wayne IN 46806-1738

Pending Applications

Programs Applied For Date Application Received Case Number SNAP JANUARY 22, 2024 T197252961

Cash JANUARY 22, 2024 T197252961

00000002000002006363000002

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Assistance Groups

Type of Assistance: The

Healthy Indiana Plan

Aid Category: MARP Emergency Services Only: No

Details

Status: Approved EBT Card Benefit Available Date:

Case Number: 601******* Current Month Amount:

AG Number: 32572208 Next Month Amount:

Effective Date: MARCH 01, 2021 Redetermination Month: FEBRUARY 2024 End Date: Monthly Liability (Health Coverage):

Previous Months Benefit Amount: N/A

Assistance Group Clients

Names Participation Status Effective Date End Date Zachery S Barnes Eligible MARCH 01, 2021

Authorized Representative

Primary Name Primary Address