MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION INSURANCE AND PREPAID BURIAL LETTER
FROM	ELIGIBILITY SPECIALIST	TELEPHONE NUMBER - -	DATE 3/28/2022
ADDRESS (STREET)
CITY, STATE, ZIP CODE ,
TO	NAME OF INSURANCE COMPANY
ADDRESS (STREET)
CITY, STATE, ZIP CODE ,
RE	CASE NAME	CASE DCN
Dear Sir/Madam:
The above named person is unable to furnish us with current insurance information. In order to determine eligibility for assistance, it is important that we know the amount of insurance in the household. Please complete the information requested below. If your records show any other policies not listed, but carried by these persons, please include them. We are enclosing a self-addressed envelope for your reply. Your prompt attention in this matter is appreciated.
AUTHORIZATION FOR RELEASE OF INFORMATION
(NAME) (DATE)
PLEASE NOTE: In order to comply with Federal regulations, our Agency is required to make a local decision on this application within TWENTY-EIGHT (28) days. We are unable to make this decision without your help and cooperation. Sincerely,
Enclosures	/
ELIGIBILITY SPECIALIST LOAD NUMBER
NAME OF INSURED	POLICY OR PLAN NO.	DATE OF ISSUE	FACE VALUE	CASH SURRENDER VALUE	IF SURRENDERED, DATE & AMOUNT PAID	LIEN/LOAN	BENEFICIARY
OTHER COMMENTS
SIGNED	TITLE	DATE
MO 886-0686 (E 04/06)	DESTROY WHEN RECORDED ON IM-37 (EXCEPT WHEN IT AFFECTS ELIGIBILITY)	IM-9 (E 04/06)

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