MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

MO HEALTHNET UNDUE HARDSHIP WAIVER DECISION

FROM	FSD OFFICE	TELEPHONE NUMBER - -	DATE April 22, 2014
OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)
, MISSOURI
TO	NAME
ADDRESS (STREET OR P.O. BOX NO.)
CITY STATE ZIP ,
RE	CASE NAME 0 DCN 0	SPOUSE 0 DCN 0
This is to advise you of the decision concerning your request for waiver of transfer of assets penalty. Based on information provided by you, we have made the following determination:
Your request for Undue Hardship Waiver is approved effective:
Your request for Undue Hardship Waiver is denied because you have not satisfactorily proven an undue hardship exists. It was found that application of the transfer of assets penalty would not deprive you of medical care such that your health or life would be in danger or that you would be deprived of food, clothing, shelter or other necessities of life. 42 U.S.C 1396p (2)(D) (per Deficit Reduction Act of 2005 Title VI ch2 sec 6011 (d)).
If you do not agree with this decision, you have the right to ask for a hearing within 90 days of the date of this letter. To request a hearing, contact the FSD Information Center 1-855-373-4636 or request a hearing by mail or in-person at an FSD office. If you request a hearing, we will schedule it for you and notify you of the time of the hearing. At the hearing, you may present your information yourself or may ask anyone else to assist you. You have the right to present witnesses in your behalf and to question witnesses who appear at the request of the Family Support Division. To see if you can get free legal service, call - - . If your situation changes, it is your responsibility under the law to report these changes at once to your local FSD office. The law provides penalties for any persons who receive benefits to which they are not entitled through misrepresenting the facts or not reporting full information about their situation.
ELIGIBLITY SPECIALIST	LOAD	TELEPHONE NUMBER - -
(04/2014)	IM-63 HWD