MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION REQUEST FOR INFORMATION
FROM	COUNTY OFFICE	TELEPHONE NUMBER - -	DATE 10/13/2017
COUNTY OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)
TO	NAME	Head of Eligibility Unit
ADDRESS (STREET)	DCN
Head of Eligibility Unit DCN
CITY STATE ZIP CODE
PROGRAM
The items and/or tasks listed below must be returned to this office and/or completed to determine your eligibility for assistance. All items pertain to you and/or all members included in your eligibility unit. Failure to provide the requested information may affect the decision made on your case.
To avoid any delays in the processing of your case, return the items and/or complete the tasks listed below no later than .
PROOF OF:
IMPORTANT IMPORTANT IMPORTANT IMPORTANT IMPORTANT IMPORTANT
IF YOU HAVE ANY QUESTIONS OR EXPERIENCE A DELAY IN SECURING ANY OF THE ABOVE ITEMS, CONTACT YOUR WORKER IMMEDIATELY:
Eligibility Specialist	Load	Phone - -	Fax - -

IM-31A ELECTRONIC (012010)