MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

AGENCY ACTION WITHDRAWN PARTICIPANT NOTIFICATION

FROM	COUNTY OFFICE	TELEPHONE NUMBER - -	DATE 4/1/2013
ADDRESS (STREET)
CITY	STATE MO	ZIP
COUNTY MANAGER
TO	NAME
CITY	STATE	ZIP
RE	CASE NAME	CASE DCN
You 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) Your request for an Administrative hearing was submitted, but as of _ ________ a hearing has not been scheduled. (DATE) On _ ____________, the Family Support Division withdrew the following action(s): (DATE)
There will not be an administrative hearing, if the hearing has been scheduled it will be cancelled. Because the action was withdrawn, you will receive a hearing decision that states the agency has rescinded the action dated ________, and there are no longer any appealable matters. There are no adverse affects to your benefits. If you have questions, please call the Family Support Information Center toll free at 855-373-4636
SIGNATURE OF ELIGIBILITY SPECIALIST	DATE
SIGNATURE OF SUPERVISOR	DATE

IM-90B (04-2013)