Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: APRIL 2023 – QUARTERLY FORMS UPDATE
DISCUSSION:
Income Maintenance forms and documents are reviewed and revised quarterly and as necessary. New forms and documents are created as required or requested.
All new and revised forms show a revision date of 4/2023. Revised forms with older revision dates are now obsolete. Family Support Division (FSD) will accept obsolete forms until 6/30/2023.
New and Revised Forms available in the public and internal forms manuals:
| Form Number | Form Name | New or Revision: |
| CARS-8 | Request for Reduction of Claim | Revised to update terminology and remove unnecessary fields. |
| CARS-8 Instructions | Instructions for Request for Reduction of Claim | Revised to update terminology and remove unnecessary fields. |
| IM-1MAC |
Addendum to MO HealthNet Application: Request for optional cash benefits |
Revision to allow electronic signatures. New PDF format. |
| IM-1MAC (Spanish) | Complemento de la Solicitud de MO HealthNet: Solicitud de Beneficios Opcionales en Dinero en Efectivo | Revision to allow electronic signatures. |
| Appointing an Authorized Representative | Revision to change MO HealthNet (MHN) terminology to annual renewal. | |
| IM-6AR (Spanish) | Designacion de un Representante Autorizado | Revision to change MHN terminology to annual renewal. |
| IM-31F | Applying for SNAP Benefits | Revision to clarify that Residency verification is only required when questionable. |
| IM-31F (Spanish) | Solicite beneficios del SNAP | Revision to clarify that Residency verification is only required when questionable. |
| IM-110 | Statement of Loss/Replacement Request | Revision to use central mail address. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision: |
| FSD/SMH Cover | MO HealthNet Application for DMH Consumers in a State Mental Hospital | Form was revised by DMH to provide updated application processes and information for DMH staff. This form has a revision date of 9/2022. |
| IM-1U90 | Annual Renewal Received Outside Reconsideration Period | Revision to change form name and MHN terminology to annual renewal. |
Obsolete forms should no longer be used by FSD staff and will NOT be accepted after 6/30/23. These forms are no longer in use with current FSD processes. In addition to forms listed above with older revision dates, the following forms are also obsolete:
| Form Number | Form Name |
| CARS-7 | Food Stamp Repayment Agreement |
| IM-34 AEG | MO HealthNet Informational Notice |
| MRT Checklist | |
| IM-115 | Request for Food Stamp Household Report |
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Begin using revised forms immediately.
- Discard and recycle blank obsolete forms.
- Share with community partners.
KE/cj