MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION NOTIFICATION OF REQUIREMENT TO TRANSFER ASSETS
FROM	CASEWORKER NAME	TELEPHONE NUMBER - -	DATE March 28, 2022
COUNTY ADDRESS
TO	NAME
ADDRESS (STREET)
CITY STATE ZIP CODE
RE	CASE NAME	CASE NUMBER
When you applied for nursing care vendor benefits, you agreed that if you were approved, you would transfer an amount of your non-exempt assets up to the spousal share to your spouse who lives at home. You agreed to take this action within ninety (90) days from the date you were approved for benefits. Based on the information you provided, we have determined your non-exempt assets to be:
You may keep no more than of these assets in your name in order to continue your eligibility past . (DATE) You must take any and all actions necessary to have your name removed form these assets by the above noted date. This may require settling up separate bank accounts, changing ownership on titles or deeds, liquidating property, or similar actions. You must also provide verification to your caseworker that your name has been removed from the asset. After , we will consider all assets in your name, including jointly owned assets, as your resource in determining your continued eligibility for nursing care vendor benefits. Your Family Support Division caseworker is available to discuss the transfer of assets process with you. However only you can decide which assets you will actually transfer to your spouse.
CASEWORKER SIGNATURE	LOAD NUMBER
MO 886-2206 (9-89)/E 05-2004	PERMANENT IM-79A (9-89)/E 05-2004