MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

AGENCY ACTION RESCINDED

FROM	COUNTY OFFICE	TELEPHONE NUMBER - -	DATE 3/30/2012
ADDRESS (STREET)
CITY	STATE MO	ZIP
COUNTY MANAGER
TO	NAME , Hearing Officer
DLS Administrative Hearings Unit
CITY	STATE	ZIP
RE	CASE NAME	CASE DCN
The above Claimant requested an Administrative Hearing on the program marked below:
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
The Administrative Hearing is scheduled for _ ______________ at _ ______________. (DATE) (TIME) The Administrative Hearing Request form (IM-87) dated _ _________ was submitted, but as of (DATE) _ ________ a hearing has not been scheduled. (DATE) On _ ____________, the Family Support Division rescinded the following action(s): (DATE)
SIGNATURE OF ELIGIBILITY SPECIALIST	DATE
SIGNATURE OF SUPERVISOR	DATE