MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MO HEALTHNET UNDUE HARDSHIP WAIVER REQUEST
FROM	ELIGIBILITY SPECIALIST	TELEPHONE NUMBER - -	DATE 04/22/2014
OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) ,
TO	NAME	CASE NAME
ADDRESS (STREET)	CASE NUMBER
CITY, STATE ZIP CODE	TELEPHONE NUMBER - -
Use this form to request an undue hardship waiver or to authorize the nursing facility where you reside to request the waiver on your behalf. Please describe, in the space provided on the back of this form, the extent of your hardship and how this transfer of assets penalty will endanger your health, life or deprive you of food, clothing, shelter or other necessities of life. In addition to your statement on the back of this form, you will need to submit the following verification: A statement signed by you (or your authorized representative) which describes whether the transferred assets are recoverable and if not, the legal attempts that were made to recover the transferred assets. AND Proof that an undue hardship will exist if the penalty period is imposed. If you are currently in a nursing facility, you must submit: A copy of the notification sent from the nursing facility, which states both the date of the involuntary discharge and alternate location, or other proof that if the hardship waiver is not granted you will be deprived of medical care such that your health or life would be endangered, or you will be deprived of food, clothing, shelter, or other necessities of life. If you are applying for or receiving Home and Community Based Service (HCB), Missouri’s Children with Developmental Disabilities (MOCDD), or Program of All Inclusive Care for the Elderly (PACE) submit: An estimate of the cost of the Long Term Care services needed to meet your medical and remedial needs, as determined by your DHSS Care Manager; and An estimate of your monthly costs for food, shelter, clothing and other necessities of life. Authorization for the Nursing Facility Administrator to Represent You The nursing facility where you reside can also make the undue hardship request for you, but they must have your permission to do so. If you would like the nursing facility where you reside to help you request an undue hardship, please check the following box and list the facility administrator’s name.
I	authorize
Print Your Name	Name of Facility Administrator
Facility Name	Facility Address
to file an undue hardship waiver request on my behalf, for the purpose of determining whether or not an undue hardship exists. If the nursing facility administrator has your permission to do so, the administrator can represent you during the appeal process if your undue hardship request is denied. Check the box next to the following statement and identify the administrator of the facility where you reside to authorize the administrator to represent you throughout the appeal process.
I	authorize
Print Your Name	Name of Facility Administrator
Facility Name	Facility Address
to represent me and/or file an appeal on my behalf regarding the denial of my undue hardship request.
Use the space below to explain the extent of your hardship and how this transfer of assets penalty will endanger your health, life, or deprive you of food, clothing, shelter or other necessities of life. Attach a separate sheet of paper if you need more space.
My signature below certifies under penalty of perjury that all declarations made in this waiver request are true, accurate, and complete.
SIGNATURE – APPLICANT/PARTICIPANT	DATE SIGNED
LEGAL GUARDIAN/AUTHORIZED REPRESENTATIVE	DATE SIGNED