S MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF FAMILY SERVICES

W TRANSITIONAL MO HEALTHNET

S	SECOND QUARTERLY REPORT

FSD OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) , MO	ATTACH COUNTY LABEL ABOVE
CASE DCN	RETURNED BY
TEAM MEMBER
TELEPHONE
THIS IS YOUR SECOND TRANSITIONAL MO HEALTHNET QUARTERLY REPORT FORM. YOU WILL RECALL WE TOLD YOU ABOUT THIS REPORTING REQUIREMENT FOR THE SECOND SIX MONTHS OF TRANSITIONAL MO HEALTHNET WHEN WE CLOSED YOUR MO HEALTHNET FOR FAMILIES CASE. COMPLETE THE FORM AND RETURN IT TO US BY , IN ORDER FOR YOUR HEALTH CARE COVERAGE TO CONTINUE BEYOND . IF YOU DO NOT SEND THE COMPLETED REPORT BY THE DATE SHOWN; WE WILL STOP YOUR HEALTH CARE BENEFITS EFFECTIVE . DURING THIS SECOND SIX-MONTH PERIOD, YOUR TRANSITIONAL MO HEALTHNET COVERAGE WILL COVER THE SAME SERVICES AS THE FIRST SIX MONTHS. YOU ARE NOT REQUIRED TO PAY A PREMIUM FOR THESE BENEFITS. YOU MUST INCLUDE INFORMATION ABOUT EARNED INCOME RECEIVED AND FAMILY MEMBERS MOVING IN OR OUT.
ENTER GROSS EARNED INCOME RECEIVED IN THE MONTHS OF , , AND
NAME OF PERSON WITH JOB	EMPLOYER NAME
(MONTH, YEAR)	(MONTH, YEAR)	(MONTH, YEAR)
IF YOU HAD NO EARNINGS IN ANY OF THE MONTHS, PLEASE EXPLAIN WHY.
ENTER EARNED INCOME FROM ANY OTHER JOB OR ADDITIONAL PERSONS WITHIN THE HOUSEHOLD. ENTER GROSS EARNED INCOME RECEIVED IN THE MONTHS OF:
NAME OF PERSON WITH JOB	EMPLOYER NAME
(MONTH, YEAR)	(MONTH, YEAR)	(MONTH, YEAR)
IF YOU HAD NO EARNINGS IN ANY OF THE MONTHS, PLEASE EXPLAIN WHY.
HAVE THERE BEEN ANY OF THE FOLLOWING CHANGES IN THE PAST THREE MONTHS: FAMILY MEMBER MOVED IN OR OUT, AN ADDRESS CHANGE, AND HAS ANYONE LOST OR OBTAINED MEDICAL INSURANCE? YES NO IF YES, EXPLAIN:
IS ANYONE IN YOUR HOUSEHOLD PREGNANT? YES NO IF YES, WHO? EXPECTED DUE DATE:
IS ANYONE IN YOUR HOUSEHOLD DISABLED? YES NO IF YES, WHO?
IS ANYONE IN YOUR HOUSEHOLD BLIND? YES NO IF YES, WHO?
BY SIGNING MY NAME I AM SAYING, UNDER PENALTY OF PERJURY, THE INFORMATION I HAVE GIVEN ON THIS FORM IS TRUE, CORRECT AND COMPLETE AND I HAVE NOT WITHHELD OR FALSELY REPRESENTED ANY INFORMATION.
SIGNATURE	DATE
TELEPHONE (WORK)	TELEPHONE (HOME)

MO 886-2622 (11/2014)	IM-55B (11/14)