MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION REQUEST FOR PUBLIC ASSISTANCE INFORMATION – OUTSIDE STATE OF MISSOURI
FROM	COUNTY OFFICE NAME	TELEPHONE NUMBER	DATE 12/5/2013
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 - -
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	Other
Previously received benefits in your state
In accordance with RSMo 208.010, we are attempting to verify the following information:
Type of Assistance	Case Status
Food Stamps	Active Closed Date closed: ______________
Temporary Assistance for Needy Families	Active Closed Date closed: ______________
Medicaid	Active Closed Date closed: ______________
Other ______________________________________	Active Closed Date closed: ______________
Comments
I authorize the release of information as indicated above. I hereby release any person or firm from any liability for information furnished pursuant to this authorization. Household Member Signature ____________________________________________________Date _____________
FAMILY SUPPORT DIVISION	PHONE NUMBER

MO 886-1760 E 11/2013	DISTRIBUTION: ORIGINAL – SEND TO RECEIVING AGENCY	IM-39A (05/06)

COPY – CASE FILE – DESTROY WHEN INFORMATION IS RECEIVED

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