MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

WITHDRAWAL OF REQUEST FOR HEARING

FROM	COUNTY OFFICE	TELEPHONE NUMBER - -	DATE 2/28/2014
ADDRESS (STREET)
CITY	STATE MO	ZIP
COUNTY MANAGER
TO	NAME
CITY	STATE	ZIP
RE	CASE NAME	CASE DCN
My continued eligibility for has been discussed with me by a representative of the Family Support Division.
I understand that the proposed action will be taken to: Reduce benefits to $ Decrease Food Stamp benefits to $ Discontinue benefits Reject an application Other: I understand that the Family Support Division has withdrawn their proposed action to: Reduce benefits to $ Decrease Food Stamp benefits to $ Discontinue benefits Reject an application Other: On the basis of the above information, I approve the Family Support Division to withdraw their proposed action dated I have discussed the proposed action with the Family Support Division. I agree with the decision previously made by the Family Support Division. By signing this from I am withdrawing my request for a hearing on the above issue. I understand that my eligibility for assistance will: Continue at the current rate Result in a reduced benefit Be discontinued or rejected My eligibility for assistance may be re-determined at a future date. At that time, if a change in eligibility is proposed I will have a right to a hearing on that action.
SIGNATURE	DATE
SIGNATURE OF FAMILY SUPPORT DIVISION I HEREBY CERTIFY that I have explained the eligibility factors and agency withdrawal of proposed action dated:	DATE

IM-90 (May 2013)