/ MISSOURI DEPARTMENT OF SOCIAL SERVICES
FAMILY SUPPORT DIVISION
REQUEST FOR INFORMATION

FROM

/

COUNTY OFFICE

/

TELEPHONE NUMBER

-- /

DATE

COUNTY OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)

TO

/ NAME / Head of Eligibility Unit
ADDRESS (STREET) / DCN
Head of Eligibility Unit DCN
CITYSTATEZIP CODE
PROGRAM
MO HealthNet for Families Prior Quarter Coverage Request
The items and/or tasks listed below must be returned to this office and/or completed to determine your eligibility for assistance. All items pertain to you and/or all members included in your eligibility unit. Failure to provide the requested information may affect the decision made on your case.
To avoid any delays in the processing of your case, return the items and/or complete the tasks listed below no later than .
PROOF OF:
Our records show that the following person(s) requestedmedical coveragein the 3 months prior to your application for MO HealthNet for Families benefits:
(3 months ago = ______, 2 months ago = ______, and 1 month ago = ______)
Name: ______
For which months is this person requesting coverage? ☐3 months ago ☐2 months ago ☐1 month ago
For which months does this person have unpaid medical bills? ☐3 months ago ☐2 months ago ☐1 month ago
For which months was this person a resident of Missouri? ☐3 months ago ☐2 months ago ☐1 month ago
If this person is not currently a Missouri resident, but was a Missouri resident in the 3 previous months, what county did they live in each month?
3 months ago______2 months ago ______1 month ago ______
Name: ______
For which months is this person requesting coverage? ☐3 months ago ☐2 months ago ☐1 month ago
For which months does this person have unpaid medical bills? ☐3 months ago ☐2 months ago ☐1 month ago
For which months was this person a resident of Missouri? ☐3 months ago ☐2 months ago ☐1 month ago
If this person is not currently a Missouri resident, but was a Missouri resident in the 3 previous months, what county did they live in each month?
3 months ago______2 months ago ______1 month ago ______
Name: ______
For which months is this person requesting coverage? ☐3 months ago ☐2 months ago ☐1 month ago
For which months does this person have unpaid medical bills? ☐3 months ago ☐2 months ago ☐1 month ago
For which months was this person a resident of Missouri? ☐3 months ago ☐2 months ago ☐1 month ago
If this person is not currently a Missouri resident, but was a Missouri resident in the 3 previous months, what county did they live in each month?
3 months ago______2 months ago ______1 month ago ______
Name: ______
For which months is this person requesting coverage? ☐3 months ago ☐2 months ago ☐1 month ago
For which months does this person have unpaid medical bills? ☐3 months ago ☐2 months ago ☐1 month ago
For which months was this person a resident of Missouri? ☐3 months ago ☐2 months ago ☐1 month ago
If this person is not currently a Missouri resident, but was a Missouri resident in the 3 previous months, what county did they live in each month?
3 months ago______2 months ago ______1 month ago ______

IM-31APQ(02/2018)

REQUEST FOR INFORMATION Continued
Head of Eligibility Unit / DCN
Program: MO HealthNet for Families Prior Quarter Coverage Request
PROOF OF: Household Income
Income from Employment 1:
Employer name, address and phone number: ______
Wages/tips (before taxes) for each of the months is being requested: ______
3 months ago $ ______2 months ago $______1 month ago $______
Income from Employment 2:
Employer name, address and phone number: ______
Wages/tips (before taxes) for each of the months is being requested: ______
3 months ago $ ______2 months ago $______1 month ago $______
Income from Employment 3:
Employer name, address and phone number: ______
Wages/tips (before taxes) for each of the months is being requested: ______
3 months ago $ ______2 months ago $______1 month ago $______
Self-employment:
If self-employed, answer the following questions:
a. Type of work ______
b. How much net income (profits once business expense were paid) did this person get from self-employment for each of the months coverage is being requested:
3 months ago $ ______2 months ago $______1 month ago $______
Other income: List other income the household has received, such as unemployment, pensions, Social Security, retirement accounts, alimony received, net farming/fishing, net rent/royalty or other income type.
NOTE: Income types including child support, veteran’s benefits, gifts Supplemental Security Income (SSI), American Indian/Alaskan Payments, and educational assistance do not count for certain types of MO HealthNet Assistance. Only tell us about these types of income if you are applying for someone who is age 65 or older, or who has a disability.
Person:______Income type: ______
3 months ago $ ______2 months ago $______1 month ago $______
Person:______Income type: ______
3 months ago $ ______2 months ago $______1 month ago $______
Person:______Income type: ______
3 months ago $ ______2 months ago $______1 month ago $______
Deductions: If this household pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: Do not include a cost that is already considered in the answer to net self-employment
Person:______Deduction type: ______
3 months ago $ ______2 months ago $______1 month ago $______
Person:______Deduction type: ______
3 months ago $ ______2 months ago $______1 month ago $______
Person:______Deduction type: ______
3 months ago $ ______2 months ago $______1 month ago $______
Other: Gross income is the amount of income BEFORE taxes and other expenses are taken out. We need this information to check your eligibility for health coverage. We will check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof.
IMPORTANT IMPORTANT IMPORTANT IMPORTANT IMPORTANT IMPORTANT
IF YOU HAVE ANY QUESTIONS OR EXPERIENCE A DELAY IN SECURING ANY OF THE ABOVE ITEMS, CONTACT YOUR WORKER IMMEDIATELY:
Eligibility Specialist / Load / Phone
-- / Fax
--

IM-31A PQ (02/2018)