Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: OCTOBER 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 IM forms show a revision date of 10/2023, unless otherwise stated. Revised IM forms with older revisions 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: |
| CARS-8 | Request for Reduction of Claim | Revision to update the Department of Social Services (DSS) logo. |
| Changing Support Order | Revision to update the DSS logo. This flyer has a 9/2023 revision date. | |
| Aged, Blind, and Disabled Supplement |
Revision to update the DSS logo. |
|
| IM-1BC | Breast and Cervical Cancer Treatment (BCCT) MO HealthNet Application | Revision to update the DSS logo. |
|
IM-1CC IM-1CC (Large Print) IM-1CC (Spanish) |
Application for Child Care Subsidy | Revision to update the DSS logo. |
| MO HealthNet Application Addendum: Request to Add Cash Benefits | Revision to update the DSS logo. | |
| Multi-Language Interpreter Services | Revision to update the DSS logo. | |
| Appointing an Authorized Representative | Revision to update the DSS logo. | |
| Applying for SNAP Benefits | Revision to update the DSS logo. | |
| Allowed Verification | Revision to update the DSS logo. | |
| Information Notice – Regarding Action Taken on Your Case – Accuity | Revision to update the DSS logo. | |
| Information Notice – Regarding Action Taken on Your Case – Accurint | Revision to update the DSS logo. | |
| Information Notice – Regarding Action Taken on Your Case – Equifax | Revision to update the DSS logo. | |
| Waiver of 10 Day Advance Notice | Revision to update the DSS logo. | |
| Online Hearing Request | Revision to update the DSS logo. | |
| Online Cancel Hearing Request | Revision to update the DSS logo. | |
| Voluntary Repayment Authorization Form | Revision to update the DSS logo. | |
| Suspending Incarcerated Participants | Revision to update the DSS logo. | |
| Inpatient Coverage for Incarcerated Participants | Revision to update the DSS logo. | |
| Restoring a Suspended Participant Change Report | Revision to update the DSS logo. | |
| Applying for Incarcerated Participants in Department of Corrections | Revision to update the DSS logo. | |
| Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement | Revision to update the DSS logo. | |
| Veterans Administration Verification (Vendor) | Revision to change form number (previously FA-312) and update the DSS logo. | |
| Veterans Administration Vendor Letter | Revision to change form number (previously FA-313) and update the DSS logo. | |
| Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) Provider Request | Revision to update the DSS logo. | |
| Childcare Outreach flyer | Revision to add a form number and update the DSS logo. | |
| School Outreach flyer | Revision to add a form number and update the DSS logo. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision: |
| IM-31Q | Contact Requested for Quality Control Review | Revision to update terminology and rename form. Instructions related to this form are now obsolete. |
| MO HealthNet for Families Adverse Action Notice | Revision to convert to fillable PDF. | |
| IM-311Q | Quality Control Referral to Family Support Division | Revision to update terminology and rename form. |
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