MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION SCHOOL VERIFICATION REPORT
COUNTY MANAGER TELEPHONE NO.	DATE
FROM	- -	March 28, 2022
FAMILY SUPPORT DIVISION
STREET ADDRESS
CITY STATE ZIP
NAME
TO
ADDRESS (STREET OR P.O. BOX NO.)
CITY STATE ZIP
CASE NAME DCN
RE
Federal Regulations require: Temporary Assistance children age 16 or over be enrolled in school or registered for work with the Division of Employment Security. An applicant for Food Stamps and any member of the food stamp household, age 18 and over, be exempt from work registration requirement if they are enrolled at least half-time in any recognized school or training program. Earnings of children under 18 years of age are excluded if that child is attending at least half-time any school or recognized training program. Please check whether the following child(ren)/person is in regular attendance at your school. If you check “No” for a student, please make a brief statement under “Remarks” regarding your knowledge of the situation. If the student is less than a full-time student, explain the student’s status under “Remarks”. IN ADDITION, PLEASE CORRECT THE NAME AND/OR ADDRESS LISTED BELOW IF IT DOES NOT AGREE WITH YOUR RECORDS. Please return this letter promptly. For your convenience, a self-addressed envelope in enclosed, or you may FAX your response to - - . Please note that to comply with Federal regulations our agency must make a decision on applications within 28 days. We must have the information requested on this form to make our decision. need thiinformation to make our decision.
AUTHORIZATION OF PARENT (NAME) DATE	AUTHORIZATION OF STUDENT (NAME)(18 YEARS OF AGE OR OLDER) DATE
STUDENT’S NAME ADDRESS	FULL-TIME	HALF-TIME	EXPECTED GRADUATION
YES	NO	YES	NO	DATE
REMARKS
TEACHER, PRINCIPAL, OR DESIGNATED AUTHORITY	DATE
MO 886-0687 (01-2014)	RETAIN CURRENT FORM	IM-10 (01-2014)