Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: APRIL 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 04/2024, unless otherwise stated.
New and Revised Forms available in the public and internal forms manuals:
| Form Number | Form Name | New or Revision: |
| IM-4Fraud IM-4Fraud (Spanish) |
Information you need about Public Assistance Fraud | Revision to update terminology and contact information. Now also available in Spanish. Revision date 2/2024. |
| IM-85 | Online Hearing Request | Revision to fillable form fields, no change to any content. |
| MO 231-0167 | Missouri Voter Registration Application | Revision completed by Secretary of State to add Political Party change as reason for new Missouri Voter Registration Application. Revision date 8/2023. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision: |
| IM-1U90 | Annual Renewal Received Outside Reconsideration Period | Revision to update DSS logo. |
| IM-34ERRN | Early Return of Renewal Notice | Revision to update DSS logo. |
| IM-40 IM-40 (Spanish) |
Citizen/National/Eligible Immigrant Attestation | Revision to update DSS logo. Spanish translation now available. |
| IM-45PLC | Protected Load Coversheet | Revision to add form number and add to internal forms manual. |
| IM-45PLR | Protected Load Request | Revision to add form number and add to internal forms manual. |
| IM-80PRE IM-80PRE (Spanish) |
Pre-Closing Notice | Revision to update language to match the system generated notice. |
| IM-160 | Advance Notice of your Administrative Disqualification Hearing | Revision to update DSS logo. |
| IM-160P | Administrative Disqualification Packet | Revision to update DSS logo. |
| IM-161 | Waiver of Administrative Hearing Disqualification Consent Agreement | Revision to update DSS logo. |
Obsolete forms are no longer in use with current FSD processes. The following forms are obsolete and have been removed from the forms manuals:
| Form Number | Form Name |
| Certification of State Employment | |
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ABAWD Volunteer Agreement
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| SSI/SSDI Transition Letter | |
| IM-14 | Request for Interpretation Policy |
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Begin using revised forms immediately.
- Share with community partners.