MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION IMPORTANT INFORMATION ABOUT ELECTRONIC BENEFIT TRANSFER (EBT) TRANSACTIONS AND PUBLIC ASSISTANCE FRAUD
Purpose: To provide a signed statement to the Family Support Division from applicant/participant Case Name: DCN: acknowledging the following: MISUSE OF YOUR FOOD STAMPS BENEFITS IS A VIOLATION OF STATE AND FEDERAL LAWS The Food Stamps benefits in your EBT account are ONLY for your household. Do NOT sell, trade, or give away your Food Stamps benefits, PIN or EBT Card. Do NOT allow a retailer, or anyone else to buy your Food Stamps benefits in exchange for cash. Do NOT purchase non-food items, such as alcohol or cigarettes, or pay credit accounts with your Food Stamps benefits. Do NOT purchase food items with your Food Stamp benefits and then sell the food items for cash, return the items for cash, or dump the contents and return the containers for the deposit. Do NOT use someone else’s Food Stamps benefits or EBT Card for your household. Multiple EBT card replacements may result in a referral for investigation of possible fraud. Misuse of Food Stamp benefits may result in disqualification from the Food Stamp program or in criminal penalties. This is to certify that I understand the statements on this form. FOOD STAMP APPLICANT/PARTICIPANT SIGNATURE: DATE:
MISUSE OF YOUR TEMPORARY ASSISTANCE BENEFITS IS A VIOLATION OF STATE AND FEDERAL LAWS Missouri law requires that the assistance provided under the Temporary Assistance Program must be used for the benefit of the child or children. Senate Bill No. 251; 208.024 (2013) prohibits TA EBT transactions in: liquor stores, casinos, gambling casinos, or gaming establishments, retail establishments which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment, and any places or for any items that are primarily marketed for or used by adults eighteen or older and/or are not in the best interest of the child or household. Your Temporary Assistance EBT transactions will be monitored. Misuse of Temporary Assistance benefits may result in another person being assigned as payee for your benefits, and/ or in referral for investigation of possible fraud. This is to certify that I understand the statements on this form.
TEMPORARY ASSISTANCE APPLICANT/PARTICIPANT SIGNATURE:	DATE:
PERMANENT IM-3 EBT (07/13)

PUBLIC ASSISTANCE FRAUD IS AGAINST STATE AND FEDERAL LAWS SB 251 revised RSMo 578.375 to 578.389. Effective August, 28, 2013, these provisions make unlawfully: Receiving/Using Converting or Transferring public assistance benefits (which includes Food Stamps, Temporary Assistance, and MO HealthNet), or EBT cards with a value of $500 or more a class D felony for the first offense. A second felony offense will result in a class C felony. If the value is less than $500 it will be a class A misdemeanor for the first offense and a class D felony for the second offense. Those who are found guilty of felony unlawfully receiving, converting, or transferring public assistance benefits or EBT cards shall serve 120 days in the Department of Corrections unless such person pays full restitution within 30 days of the date of execution of the sentence. If they are placed on probation for the offense they cannot be released from probation until full restitution has been paid. This is to certify that I understand the statements on this form.
APPLICANT/PARTICIPANT SIGNATURE:	DATE:
PERMANENT IM-3 EBT (07/13)