MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION DISCHARGED PAROLEE DRUG CONVICTION EXCEPTION VERIFICATION
Instructions for FSD: FOR INDIVIDUALS WHO HAVE COMPLETED PAROLE Enter name, DCN, Social Security Number and Date of Birth of individual requesting exception from the drug felony conviction disqualification. Enter the appropriate email address in the return to line. Send form for completion to the Department of Corrections, Board of Probation and Parole Custodian of Records: Pam Rogers at pam.rogers@doc.mo.gov.
NAME: ________________________________________________ DCN: _________________________________ SOCIAL SECURITY NUMBER: _____________________________ DOB: __________________________________ RETURN TO: _____________________________________________
BOARD OF PROBATION AND PAROLE TO COMPLETE THE FOLLOWING: Please mark yes, no, or not applicable where indicated regarding the following person’s Parole compliance as related to their felony drug conviction.
If the individual was on parole: The Board of Probation and Parole has discharged this individual from parole. Completion Date: ____________________________	Yes No N/A
Name: ____________________________________________ Date: ___________________________ Title:_____________________________
I certify that I have given true, accurate, and complete statements to the best of my knowledge.

IM-368