MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION REVIEW NOTICE
FROM	COUNTY OFFICE	DATE 08/02/2010
ADDRESS
ADDRESS
CITY STATE ZIP CODE
TO	NAME
ADDRESS (STREET)
CITY	STATE MO	ZIP CODE
RE	CASE NAME	CASE NUMBER
The Family Support Division is required to review the eligibility of persons for assistance. In order
to determine eligibility, we are asking that you complete all sections in the white area only of the attached form.
DO NOT WRITE IN THE GRAY AREA.
Please read each item carefully before you answer it. The answers you give will be used to determine if you
are eligible to receive financial and/or medical help. A friend or relative may help you complete the form. If
you need any assistance in completing the form, or if there are any areas you do not understand, please contact
your eligibility specialist.
After you have completed the form, please sign on the line indicated for applicant/participant.
Please complete the form today and return it in the enclosed envelope. If the Adult Supplemental Form, Medical
Authorization Form or any other forms are attached, please complete and sign these also and return them with
the eligibility statement.
Failure to return the form may result in your case being closed.
If any one in your household has earned income, please attach the past two months pay stubs or verification
of earnings from your employer. In addition, please attach verification of any unearned income such as award
letters, and/or your most current checking and savings account statements. At your request, these documents
will be returned to you.
If you have any questions, contact your eligibility specialist.
ELIGIBILITY SPECIALIST NAME	TELEPHONE NUMBER - -	CASELOAD NUMBER
DAY OF WEEK	MONTH - DATE
PLEASE RETURN THIS FORM BY
MO 886-0665 (9-09)	DESTROY ON CASE ACTION COMPLETION	IM-3A (9-09)