Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: JANUARY 2024 – 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 01/2024, unless otherwise stated. Revised IM forms with older revisions dates are now obsolete. Family Support Division (FSD) will accept obsolete forms until 03/31/2024.
Note: Child Care program information was removed from many FSD forms and documents as Department of Elementary & Secondary Education (DESE) systems are used for eligibility (2023 Memo IM-103).
Participants may access the Application for Child Care Subsidy for Children and Families (MO 500-3469) and additional information from the Child Care Subsidy Information for Families webpage on the DESE website.
New and Revised Forms available in the public and internal forms manuals:
| Form Number | Form Name | New or Revision: |
| IM-4Finding Help IM-4Finding Help (Spanish) |
Finding Help brochure | Revision –removed the Child Care program information. Revision date (12/2023) |
| IM-4 Employment Impacts Benefits IM-4 Employment Impacts Benefits (Spanish) |
How Employment Impacts Your Benefits flyer | Revision – removed the Child Care program information. |
| IM-4Spend Down IM-4Spend Down (Spanish) |
Spend Down flyer | Revision – added information about paying online using the My MOHealthNet Portal, corrected the link to the Spend Down Frequently Asked Questions. |
| IM-6AR IM-6AR (Spanish) IM-6AR (Large Print) |
Appointing an Authorized Representative | Revision – removed references to Child Care program, added instructions for returning the completed form to FSD. |
| IM-31B (Spanish) | Your Rights and Responsibilities as a Supplemental Nutrition Assistance Program (SNAP) Household | New – Spanish translation of IM-31B (8/2023) |
| IM-31V | Allowed Verification | Revision – removed references to Child Care program. |
| IM-63HWR IM-63HWR (Spanish) |
MO HealthNet Undue Hardship Waiver Request | Revision – updated language and formatting, moved form to public forms manual from internal forms manual |
| IM-100RWC IM-100RWC (Spanish) |
Request to Withdraw or Close | Revision – removed Child Care Program, added MO HealthNet Children’s Insurance Program (CHIP), reformatted program list |
New and Revised Online Forms
| Form Name | New or Revision |
| Replacement Request | Revision – updated to match IM-110 (9/2023) by updating non-discrimination language. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision |
| IM-32 MAGI (Spanish) | MO HealthNet Approval Notice | Revision – Spanish translation of IM-32 MAGI (12/2023) |
| IM-33 MAGI IM-33 MAGI (Spanish) |
Notice of Case Action | Revision – updated formatting, updated legal references, updated hearing and report changes language |
| IM-63HWD IM-63HWD (Spanish) |
MO HealthNet Undue Hardship Waiver Decision | Revision – updated language |
| IM-63HWN IM-63HWN (Spanish) |
MO HealthNet Undue Hardship Waiver Notice | Revision – changed form name, updated hearings and report changes language |
Obsolete forms should no longer be used by FSD staff. 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 |
| IM-1CC IM-1CC (Spanish) IM-1CC (Large Print) |
Child Care Application |
| IM-4CC IM-4CC (Spanish) |
Child Care Subsidy Brochure |
| Child Care Fraud Brochure | |
| IM-30 UCCW | Units of Care Calculation Worksheet |
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