Missouri Department of Social Services Family Support Division
Independent Living Account Designation 
CASE NAME 	CASE NUMBER 	
I have established the following Independent Living Account and will maintain it to provide savings for transportation, housing, home modification, and personal care services and assistive devices associated with my disability. 

•I will limit deposits to this account to earnings from my employment while participating in the Ticket to Work Health Assurance program.  Interest earned in this account may also remain in this account.
 
•I will not deposit other funds into this account. 

•I understand that I may not dispose of these resources for any purpose other than transportation, housing, home modification, and personal care services and assistive devices associated with my disability. 	
Description of Independent Living Account: 	
Institution Name: 	
Institution Address: 	
Type of Account: 	
Account Number: 	
	
SIGNATURE 	DATE 	
WITNESS 	WITNESS 	

MO  886-4033 (08-07) Distribution:  Original – FSD; Copy – Participant IM-99A (8-07)  Permanent