MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION CURRENT PROBATION AND PAROLE/COURT COMPLIANCE DRUG CONVICTION EXCEPTION VERIFICATION
Instructions for FSD: FOR INDIVIDUALS CURRENTLY ON PROBATION OR PAROLE Enter name, DCN, Social Security Number and Date of Birth of individual requesting exception from the drug felony conviction disqualification. Enter address of appropriate FSD office in Return to field. Provide form with a Request for Information, allowing 10 days to provide the completed form, to the individual requesting the exception from the felony drug conviction disqualification. Instruct individual to contact their current Probation or Parole officer to complete the form.
NAME: ________________________________________________ DCN: _______________________________ SOCIAL SECURITY NUMBER: _____________________________ DOB: _______________________________ RETURN TO: _____________________________________________
Instructions for the Missouri Board of Probation and Parole. Please mark yes, no, or not applicable where indicated regarding the following person’s Probation and Parole/court compliance as related to their felony drug conviction
If the individual is on probation or parole: The Missouri Board of Probation and Parole has not taken action to revoke this individual’s probation or parole.	Yes No N/A
Name: ____________________________________________ Date: ___________________________ Title:_______________________________________________
I certify that I have given true, accurate, and complete statements to the best of my knowledge.

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