MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION DRUG CONVICTION EXCEPTION DETERMINATION WORKSHEET
If you answered yes to the question: “Have you or any member of your household been convicted in a Federal or State court of a felony committed after 8-22-96 related to illegal possession and use of a controlled substance?” Please answer the following questions for the individual with a drug felony conviction. * NAME: ________________________________________________ DCN: _________________________________
A.	Please list all of the dates and types of drug convictions which occurred in a Federal or State court of a felony committed after 8-22-96, related to illegal possession and use of a controlled substance. Conviction Type: _______________________________ Date: _____________ State: _____________ Conviction Type: _______________________________ Date: _____________ State: _____________ Conviction Type: _______________________________ Date: _____________ State: _____________
Please note: You do not qualify for the drug conviction exception if you have plead guilty or no contest to, or been found guilty of, two subsequent felony drug offenses after the date of the first felony conviction.
B.	Are you currently successfully participating in a substance abuse treatment program approved by the Division of Alcohol and Drug Abuse? Treatment Center Name: __________________________ Start Date: __________________	Yes No
C.	Are you currently enrolled in a substance abuse treatment program approved by the Division of Alcohol and Drug Abuse but on a waiting list? Treatment Center Name: __________________________ Date of Enrollment: __________	Yes No
D.	Have you successfully completed a substance abuse program approved by the Division of Alcohol and Drug Abuse? Treatment Center Name: __________________________ Completion Date: ____________	Yes No
E.	Has a certified treatment provider from Division of Alcohol and Drug Abuse determined you do not need substance abuse treatment? Treatment Center Name: ___________________________ Determination Date: _________	Yes No
F.	Are you complying, or have you successfully complied, with all obligations imposed by the court, the Division of Alcohol and Drug Abuse, and the Division of Probation and Parole? Probation/Parole Officer Name: ______________________ Completion Date: ___________	Yes No
Please note: You do not qualify for the drug conviction exception if you can not answer Yes to one of B through E and Yes to F.
G.	Have you plead guilty or no contest or been found guilty of any additional controlled substance misdemeanor or felony offense after release from custody within one year after your first date of conviction? Conviction Type: ____________________________ Date: ___________ State: _________ Conviction Type: ____________________________ Date: ___________ State: _________	Yes No
H.	If you were not in custody, have you plead guilty or no contest or been found guilty of any additional controlled substance misdemeanor or felony offense within one year after your first date of conviction? Conviction Type: ____________________________ Date: ____________ State: ________ Conviction Type: ____________________________ Date: ____________ State: ________	Yes No
Please note: You do not qualify for the drug conviction exception if you must answer Yes to G or H
I.	Can you demonstrate sobriety through voluntary urinalysis testing paid for by you? Test results must be dated following last felony conviction. In-home test is not acceptable. The FSD will not pay for the urinalysis testing. You do not qualify for the drug conviction exception if you must answer No. Date of Test: ____________________ Test Result: ___________	Yes No
Name: ____________________________________________ Date: ___________________________ e penalty of perjury, I certify that I have given true, accurate, and complete statements to the best of my knowledge.

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