MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION APPLICATION FOR STATE HEARING
CATEGORY BEING APPEALED
1619	LIHEAP	MHABD-VEN	MOCDD (Sara Lopez Waiver)	SLMB	SUPP AB
BCCT	EMCIA	MHCC	MPW	SNC	TEMP ASSIST
BP	EWHS	MHDC	PE For Kids/Pregnant Women	SP	TWHA
CC	FS	MHF	QDWI	SSI	UWHS
CCP	MHABD	MHK	QMB	SSI-SP	OTHER
DWD(METP) Yes No	MWA Yes No	SANCTIONED INDIVIDUAL (FOR DWD/MWA HEARING)	SSN OF SANCTIONED INDIVIDUAL (DWD/MWA HEARING) - -
CASE NAME	CASE DCN	CASE RESIDENCE COUNTY	FSD OFFICE OF ACTION
CLAIMANT IS APPEALING (CHECK ONE) REJECTION GRANT AMOUNT/ISSUANCE CLOSING DELAY OTHER	DATE OF ACTION NOTICE FOR WHICH HEARING IS REQUESTED	DATE HEARING REQUESTED
NAME AND DCN OF PERSON THE HEARING IS FOR OR ABOUT, IF DIFFERENT THAN CASE NAME REASON FOR PLANNED ACTION OR DECISION BY AGENCY
COMPLETED BY CLAIMANT
NAME OF THE PERSON REQUESTING THIS HEARING (REFERRED TO AS CLAIMANT)	TELEPHONE NUMBER - -
HOUSEHOLD MAILING ADDRESS (STREET, RURAL ROUTE, OR P O BOX, CITY, STATE, ZIP CODE)
STATE OF MISSOURI, I hereby make application for a hearing provided by state law or department regulations.
CLAIMANT: STATE PLAINLY THE REASON YOU ARE REQUESTING A HEARING.
FOOD STAMP, TEMPORARY ASSISTANCE AND/OR MO HEALTHNET RECIPIENTS	COMPLETED BY AGENCY
26. ES or ESS THAT WILL BE AGENCY WITNESS: NAME: TELEPHONE: EXT:
If you are still certified for Food Stamps (FS), receiving Temporary Assistance (TA) and/or MO HealthNet, if you request a hearing within 10 calendar days of the date of the Notice of Adverse Action you may choose to continue receiving benefits while your hearing is pending. If the hearing decision shows that the plan to reduce your benefits or close your case was correct, you or your household will be responsible for repaying the amount of benefits you received and were not entitled to receive while your hearing was pending. If you elect to discontinue receiving benefits while your hearing is pending and the hearing decision is ruled in your favor, any lost benefits will be restored to you.
NORMAL DAILY WORK SCHEDULE:
Monday	to
Tuesday	to
Wednesday	to
Thursday	to
Friday	to
UPCOMING SCHEDULED TIME OFF:
Please check one of these boxes:
I wish to continue receiving FS TA MO HealthNet while my hearing is pending.	Date(s)	to
Date(s)	to
I do not wish to continue receiving FS TA MO HealthNet while my hearing is pending.	Date(s)	to
Date(s)	to
CLAIMANT’S REPRESENTATIVE: NAME	REPRESENTATIVE TELEPHONE NUMBER - -
CLAIMANT’S REPRESENTATIVE: ADDRESS
CLAIMANT’S SIGNATURE (OR SIGNATURE OF CLAIMANT’S REPRESENTATIVE)	DATE
COMPLETED BY AGENCY
27. DATE HEARING REQUEST SCANNED AND EMAILED TO HEARINGS UNIT	28. DATE EXHIBITS OR FOLLOW-UP DOCUMENTS MAILED TO HEARINGS UNIT
29.SIGNATURE OF ELIGIBILITY SPECIALIST	ES or ESS will be participating from FSD office. Claimant will be participating from FSD office. DATE IM-87 RECEIVED BY HEARINGS UNIT ________________________
30.SIGNATURE OF SUPERVISOR

MO 886-0751 (01/2013)	DISTRIBUTE TO: HEARING OFFICER: CASE RECORD: AGENCY WITNESS (I.E. DWD/MWA STAFF)	RETAIN 36 MONTHS IM-87 (01/2013)