State form 53391 2026

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The document is an application form for obtaining a license to operate a Personal Services Agency in Indiana. It outlines the necessary steps, required information, and documentation needed for submission, including details about ownership, staffing, policies, and fees. The application must be completed fully and legibly, accompanied by a non-refundable fee of $250.00, and includes sections for identifying information, staffing details, ownership interests, and certification of compliance with state regulations.

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Click ‘Get Form’ to open state form 53391 in the editor.
Begin with SECTION I, where you must select the type of application. Check either 'Change of Ownership' or 'New Agency' as applicable.
In SECTION II, provide identifying information about your agency. Fill in the agency name, address, contact details, and office hours clearly.
SECTION III requires staffing details. Enter the names and addresses of managers and alternate managers, ensuring all fields are completed accurately.
For SECTION IV, list ownership details. Include names and addresses of individuals with a controlling interest and their respective ownership percentages.
Complete SECTION V by certifying your application. Ensure that all signatures are provided where indicated to validate your submission.
Finally, review all sections for completeness before submitting your application along with the required fee to the Indiana State Department of Health.

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