Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: SEPTEMBER 2023 – FORMS UPDATE
DISCUSSION:
Income Maintenance (IM) forms and documents are reviewed and revised periodically, as necessary. New forms and documents are created as required or requested.
Note: Supplemental Nutrition Assistance Program (SNAP) replacement benefit forms are updated due to new replacement policies and procedures related to electronically stolen benefits. Refer to New and Revised internal forms for revisions to IM-112 and new form IM-112RB.
All new and revised IM forms show a revision date of 9/2023; previous versions of these forms with other revision dates are now obsolete. Family Support Division (FSD) will accept obsolete forms until 12/31/2023.
New and Revised Forms available in the public and internal forms manuals:
| Form Number | Form Name | New or Revision: |
| FSD-4 | Customer Service | Revision to add DSS logo and electronic signature attestation. |
| FSD-4 (Spanish) | Servicio Al Cliente | New form translating the FS-4 to Spanish. |
| IM-100RWC | Request to Withdraw or Close | Revision to add new form number, AEG program option, and non-discrimination statement. |
| IM-100RWC | Solicitud de Suspension o Cierre | Revision to IM-100RWC Spanish. |
| IM-110 | Replacement Request | Revision to add non-discrimination statement and remove office use only section. |
| IM-110 (Spanish) | Solicitud de Substitucion | New form translating the IM-110 to Spanish. |
| IM-145 | Change Report | Revision to add new question regarding pregnant household members and additional instructions for active MO HealthNet (MHN) participants requesting a different MHN program. |
| IM-145 (Spanish) | Informe de Cambios | New form translating the IM-145 to Spanish. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision: |
| IM-112 | Action Taken On Your Supplemental Nutrition Assistance Program (SNAP) Case | Revision to remove replacement benefit language and add non-discrimination statement. |
| IM-112 (Spanish) | Acción Implementada en su Caso del Programa de Asistencia Nutricional Suplementaria (SNAP) | Revision to IM-112 (Spanish). |
| IM-112RB | Action Taken on Your Request for Replacement Benefits | New form to notify participants who have requested replacement benefits due to household misfortune, stolen EBT card, or electronically stolen benefits. |
| IM-112RB (Spanish) | Medida Adoptada en su Solicitud de Sustitucion de Beneficios | New form translating IM-112RB to Spanish. |
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