MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION REQUEST FOR EMPLOYMENT SECURITY INFORMATION – OUTSIDE STATE OF MISSOURI
FROM	OFFICE NAME	TELEPHONE NUMBER - -	DATE 12/27/2013
ADDRESS (STREET)
CITY, STATE, ZIP CODE
TO	STATE AGENCY NAME
ADDRESS (STREET)
CITY, STATE, ZIP CODE ,
RE	CASE NAME	SOCIAL SECURITY NUMBER	CASE DCN
NAME (IF DIFFERENT FROM CASE NAME)	SOCIAL SECURITY NUMBER
I authorize the release of information requested below to the Family Support Division. I hereby release any person or firm from any liability for information furnished pursuant to this authorization. Household Member Signature _______________________________________________ Date ______________________ The above-named individual has applied for public assistance benefits in Missouri. Our information indicates that the participant may have:
Previously lived in your state Previously received unemployment insurance in your state	Previously worked in your state Other __________________________________
In accordance with 208.010 RSMo, we are attempting to verify the following information:
Has the individual been employed in your state? Yes No Name of Employer: ___________________________________________________________________ Employer’s Address: _________________________________________________________________ Employer’s Phone Number: ____________________________________________________________ Dates of Employment: ________________________________________________________________
Is the individual currently receiving unemployment insurance in your state? Yes* No *(Please attach printout if available) Current Benefit Amount ________________ Account Balance __________________ Last Check Date ____________ Benefits Paid Weekly ___ Bi-weekly ___ Other (please specify)__________________________________________
Comments: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ PLEASE FAX RESPONSE TO: - -
FAMILY SUPPORT DIVISION	PHONE NUMBER - -
MO 886-1760	DISTRIBUTION: ORIGINAL – SEND TO RECEIVING AGENCY COPY: CASE FILE – DESTROY WHEN ORIGINAL IS RECEIVED	IM-39 (01-2014)

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