MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION WAIVER OF 10-DAY ADVANCE NOTICE
TO	COUNTY OFFICE	DATE 05/05/2004
ADDRESS
FROM	CLAIMANT NAME	COUNTY
ADDRESS	CASE NUMBER
My eligibility for	has changed because
I understand that, because of this change, my
cash benefits will be reduced to
cash benefits will be stopped
other:
This change will be made on the check I receive beginning with the month of
(MONTH) (YEAR)
MC+/Medicaid coverage will end on
(MONTH) (DAY) (YEAR)
for the following persons:
By signing this form I am confirming that the eligibility factors have been explained to me and I understand my
benefits will cease or be modified as stated above. I further understand I am waiving my rights to a 10 day
advance period, during which I could request a fair hearing and have my benefits continue.
I am giving up my right to continue receiving benefits at the present rate if I should request a hearing later.
I understand that I cannot request a hearing until the change is made.
However, I can request a hearing on this decision within 90 days of the date of the notice I receive indicating
this change has been made.
DATE	CLAIMANT SIGNATURE
STATEMENT OF CASEWORKER
I HEREBY STATE THAT I HAVE EXPLAINED THE ELIGIBILITY FACTORS, THE CONTENTS OF THIS FORM AND RIGHTS TO A FAIR HEARING, TO AND HAVE WITNESSES HIS/HER SIGNATURE ON THE ABOVE DATE.
SIGNATURE OF CASEWORKER/CASE MANAGER	TITLE
MO 886-0748 (8-01)/E 05-2004	IM-80A (8-01)/E 05-2004