MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION AUTHORIZATION FOR RELEASE OF INFORMATION
FROM	FAMILY SUPPORT DIVISION	TELEPHONE NUMBER - -	DATE 3/24/2022
OFFICE ADDRESS
TO	NAME
ADDRESS (NUMBER AND STREET)
CITY STATE ZIP CODE
RE	CASE NAME	CASE NUMBER
I authorize the release of information regarding my situation described below to representatives of the Missouri Family Support Division.
INFORMATION SHALL BE RELEASED BY
I (we) hereby release any person, firm, physician, clinic, or hospital from any liability for information furnished pursuant to this authorization.
APPLICANT/PARTICIPANT SIGNATURE	DATE
SIGNATURE OF SPOUSE	DATE
SIGNATURE OF OTHER	DATE
ADDRESS (STREET, CITY, STATE, ZIP CODE)
MO 886-0683 (01-2014)	PERMANENT IM-6 (01-2014)