MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION INTERNAL USE ONLY REPORT OF CHANGE/NEED FOR REASSESSMENT
INDIVIDUAL NAME (FIRST)	(MIDDLE)	(LAST)	INDIVIDUAL DCN	DATE OF REPORT
Instructions: Use this form to notify processing centers of: Changes reported and acted upon in one system that must be entered in the other system. The need to register/process an application as the result of an ex parte review. Notification from a participant during the Pre-Closing or Adverse Action Notice timeframes. When completed, scan and index the form to the appropriate Work Site location.
This is a
CHANGE:
Address
Employment
Household Members
Other
EX PARTE / POTENTIAL ELIGIBILITY REASSESSMENT
Currently non-disabled program, potential for disability program found through record	For whom?
Currently non-disabled program, potential for disability program claimed by participant/household/authorized representative	For whom?
Other, explain below
Provide details of the change or circumstances of the reassessment, including whether or not an application has been registered:
Is information/verification in Work Site?	Yes	No
Participant contact information, if follow up is needed:
Report submitted by and contact information:
IM-145 OTH	10/2014