FSSA Document Cover Sheet for Case 6005078756

DOCUMENT COVER SHEET

State Form ***** (R* / *-**) / DFR 1010 / IEDSS

*FSS408AE001CUD15Q82*

Case Information

Client Name: Melissa D Hicks Address: 11292 W 525 N Case Number: 600-***-**** Delphi, IN 46923-8260

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 fssabenefits.in.gov. 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-***-****.

· 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-***-**** between 8:00 AM and 4:30 PM, local time, Monday through Friday.

Comments or Documents Included

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