CERTIFICATION FORM FOR DISASTER RELIEF ASSISTANCE
PROVIDED THROUGH THE ARC OF INDIANA MASTER TRUST
AND THE ARC OF INDIANA
 

By signing this Certification Form, you are agreeing that the recipient:

• is a person with a disability 

• is a recipient of Supplemental Security Income (SSI) or Medicaid Disability

• lives in a county declared a disaster area

• has been severely impacted by the disaster

• will use disaster relief funds for financial assistance as a result of loss from the disaster

• will use funds to supplement, not supplant, other sources of revenue used to pay monthly bills. 

Recipients Name:    _____________________________________________________________________________________ 

Address to Which Relief Can Be Mailed:

Address:   _____________________________________________________________________________________________

City: __________________________________________________    State: Indiana     Zip:   __________

Social Security Number: ___________________________________________________

Medicaid Card Number (If Applicable and Available): _____________________________ 

 

______________________________                        _______________________________

             Agency Representative Name                                        Agency Representative Signature
 

______________________________                        ________________________________

Agency Name                                                                    Address

_______________________________                      ______________________           ________________________

City                                                                                      Zip                                                      Telephone
 

Please return this form by mail or Fax to:  

The Arc of Indiana

107 N. Pennsylvania Street, Suite 300

Indianapolis, Indiana 46204          

Fax:  (317) 977-2385

For more information, call 317-977-2375 or 1-800-382-9100