MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

OUT OF POCKET EXPENSES

FROM	FSD OFFICE	TELEPHONE NUMBER - -	DATE July 20, 2012
COUNTY OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)
, MISSOURI
TO	NAME
ADDRESS (STREET OR P.O. BOX NO.)
CITY STATE ZIP ,
RE	CASE NAME 0 DCN 0	ELIGIBLE SPOUSE 0 DCN 0
This is to advise you (and your spouse if listed above) have paid in your spend down expense in the amount
of	for	and have submitted	PAID out of pocket expenses
for consideration to offset unpaid invoices for up to the next three months of service. The three month period
is	through	.
Date of Service	Provider	Amount you paid	Eligible expense Yes or NO	Reason if not eligible
Eligible charges have been entered. If you have any questions concerning the amount you should pay, contact MHD Premium Collections Unit at 1-877-888-2811. The legal reason for this decision is found in 42 CFR 435.121 and RSMO 208.153.8. If you do not agree with this decision, you have the right to ask for a hearing within 90 days of the date of this letter. To request a hearing, contact 1-855-373-4636 the FSD Information Center (toll free at 1-855-FSD-INFO) or request a hearing by mail or in-person at an FSD office. If you request a hearing, we will schedule it for you and notify you of the time of the hearing. At the hearing, you may present your information yourself or may ask anyone else to assist you. You have the right to present witnesses in your behalf and to question witnesses who appear at the request of the Family Support Division. To see if you can get free legal service, call - - . If your situation changes, it is your responsibility under the law to report these changes at once to your local FSD office. The law provides penalties for any persons who receive benefits to which they are not entitled through misrepresenting the facts or not reporting full information about their situation.
ELIGIBLITY SPECIALIST	LOAD	TELEPHONE NUMBER - -
MO 886-0697 (7-12)	IM-29OPE