MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION FINANCIAL INFORMATION REQUEST	DATE 12/27/2013
OFFICE	CASE NAME
ADDRESS	CASE NUMBER
CITY, STATE, ZIP	ADDRESS
PHONE - -	CITY, STATE, ZIP
FINANCIAL INSTITUTION NAME
ADDRESS
INSTRUCTIONS TO FINANCIAL INSTITUTION
We are determining eligibility or completing an assessment of assets in the above referenced case. We have provided the social security numbers, names and known account numbers for members of the case. This request is for financial information on all accounts of these persons. A self-addressed stamped envelope is enclosed for your convenience.
AUTHORIZATION FOR RELEASE OF INFORMATION
HEAD OF HOUSEHOLD/PAYEE NAME	SOCIAL SECURITY NO. - -	SIGNATURE	DATE SIGNED
SPOUSE/OTHER JOINT OWNER	SOCIAL SECURITY NO. - -	SIGNATURE	DATE SIGNED
NAME	SOCIAL SECURITY NO. - -	SIGNATURE	DATE SIGNED
FINANCIAL INFORMATION REQUESTED
Please provide information for the account numbers listed and any other Checking Accounts, Savings Accounts, Certificates of Deposit, Christmas Funds, Trust Accounts, any type of Individual Retirement Accounts, or other accounts of the persons named above.
ACCOUNT NUMBER
TYPE OF ACCOUNT
NAMES ON ACCOUNT
CURRENT BALANCE IF 0, ENTER DATE CLOSED AND AMOUNT WITHDRAWN
BALANCE AS OF
AMOUNT OF INTEREST EARNED
DATE INTEREST PAID
PERIOD COVERED
INTEREST RATE
DIRECT DEPOSIT REQUEST Please make my assistance payment by direct deposit to my (checking) (savings) account. DIRECT DEPOSIT
NAME TYPED	SIGNATURE	DATE
BANK OFFICIAL Please enter transit routing number, account number and type of account for direct deposit below:
TRANSIT ROUTING NUMBER	ACCOUNT NUMBER	TYPE OF ACCOUNT
CHECK AND GIVE DETAILS ON BACK IF ANY OF THE ABOVE LISTED PERSONS HAVE ANY OF THE FOLLOWING
LARGE WITHDRAWALS SAFE DEPOSIT BOX LOANS OWED STOCKS BONDS TRUST DEEDS OWED
ANY ADDITIONAL INFORMATION OR COMMENTS CONCERNING INVESTMENTS OR OTHER TRANSACTIONS WHICH YOU MAY HAVE HAD WITH THE ABOVE PERSONS WILL BE APPRECIATED. PLEASE LIST ON BACK OR ATTACH SEPARATE SHEET.
SIGNATURE OF PERSON COMPLETING FORM TITLE	TELEPHONE NUMBER	DATE
MO 886-0684 (1-2014)	PERMANENT (IM-7)