CSBG Direct Assistance:
Items required for assistance:
- Appointment required.
- Intake Sheet.
- Vision, Medical, or Dental Assistance Plan form.
- Social Security card for all household members.
NOTE: If you cannot provide your social security card, the following documents may be used along with a government issued photo ID:
- Indiana State Issued Real ID
- United States Passport
- Letter from the Social Security Administration
- Social Security Benefit Letter
- Paystub that Contains the Full SSN
- Family Demographic (Office of Family and Children)
- W-2 or 1099 (NOT hand written)
- Documentation from an Eligible Program such as:
- Medicare Benefit Letter
- S. Military ID (i.e. DD214 or AF-retired military)
- S. Government Identification
- Indiana Government ID (i.e. Dept of Corrections)
- Benefit Statement
- A birth confirmation letter from the hospital may be used for children under 1 that do not have a social security card yet.
- ID for all adults in the household.
- Income – Income Guideline: 125% FPG (All adults in the household 18 and older must provide proof of income):
- Wage Inquiry
- Check stub (Most recent paystub or if you have worked within the last 3 months and are no longer employed, provide the final paystub).
- Social Security Benefits (SSI, SSDI, SSD, SSA) /VA Pension/Veteran’s Benefit:
- Current Award Letter: Must be dated within the last year. An award letter dated over a year old will not be accepted.
- Current Bank Statement: Must clearly show deposit and who it belongs to. The bank statement cannot be marked out for any reason.
- Pension: Most Recent Check Stub OR Current Pension Award Letter
- Self-employed: Completed IRS form 1040 page 1 & 2 AND Schedule C page 1 & 2 for previous tax year.
- Child Support – 12 month print out.
- TANF – 12 month print out.
- Zero Income Verification Affidavit/Cash Income: If anyone in the household has had 1 month and/or more of no income, this form must be filled out. One form per household member.
- Vision – Nate Optometrist (812)271-1700.
His office is located at 314 S. Chestnut St. Seymour, IN 47274.
The client is eligible with up to, but not to exceed $150.00.
Covered Items:
- Routine eye exam.
- Frames
- Lenses
NOTE: Applicant is responsible for all costs not covered by Human Services, Inc. and must pay Dr. Nate Optometrist the balance in full at the time of purchase.
- Medical /Dental– Indiana Health Center (812)524-8388.
The office is located at 1113 N. Chestnut St. Seymour, IN 47274.
The client is eligible with up to, but not to exceed $100.00.
NOTE: Applicant is responsible for all costs not covered by Human Services, Inc. and must pay Indiana Health Center the balance in full at the time of purchase.
Intake Sheet
Please click the application image to open the Application PDF. Download the Intake Sheet and print. Then, fill out the form and bring with you to our office.
