MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION INTENT TO TRANSFER ASSETS AGREEMENT	DATE 03/28/2022
COUNTY NAME AND ADDRESS	TELEPHONE NUMBER - -
IDENTIFICATION INFORMATION
CASE NUMBER	INSTITUTIONALIZED SPOUSE NAME
ADDRESS (STREET, CITY, STATE, ZIP CODE)
DCN	COMMUNITY SPOUSE NAME
ADDRESS (STREET, CITY, STATE, ZIP CODE)
I understand that for married persons with a spouse living at home, initial resource eligibility for nursing care vendor benefits is determined by disregarding the amount of the spousal share. This has been explained to me. I understand that if I am found eligible for nursing care vendor benefits, in order to continue to receive benefits, the assets in my name, including jointly owned assets, cannot exceed the resource maximum for a single person. Provided I am found eligible for nursing care vendor benefits, I agree to transfer to my spouse an amount of my non-exempt assets to continue my eligibility. I understand that the Family Support Division will notify me of the amount of assets I may keep in my name and remain eligible for benefits. I understand that I have no more than (90) days from the date I am found eligible for nursing care vendor benefits to complete the transfer. I understand that I must take any and all required actions to have my name removed from these assets. I understand that this may require setting up separate bank accounts, change ownership on titles or deeds, liquidating property, or similar actions. I understand that after ninety (90) days, any and all non-exempt assets in my name, including jointly owned assets, will be considered in determining my continued eligibility for nursing care vendor benefits.
SIGNATURE OF INSTITUTIONALIZED SPOUSE	DATE
WITNESS	DATE
WITNESS	DATE
SIGNATURE OF CASEWORKER	LOAD NUMBER	DATE
MO 886-2526 (9-89)/E 05-2004	DISTRIBUTION: WHITE - FSD; CANARY - INSTITUTIONALIZED SPOUSE	PERMANENT IM-79 (9-89)/E 05-2004