Missouri Department of Health and Senior Services
|VENDOR NAME |
| |
|PARTICIPANT’S NAME AND COMMUNITY ADDRESS |DCN |
| | |
|AMOUNT REQUESTED |TRANSITION DATE |
|Indicate the items needed by the participant and anticipated cost of each item. |
|ITEM |COST |ITEM |COST |
|Rent Deposit | |Household Items: | |
|Utility Deposits | |Dishes | |
|Cleaning Supplies: | |Utensils | |
|Dish Soap | |Pots/Pans | |
|Mop/Bucket | |Cups/glasses | |
|Dish Cloths/towels | |Measuring cups/spoons | |
|Laundry Detergent | |Mixing/serving bowl | |
|Broom/dust pan | |Leftover storage containers | |
|All-purpose cleaner | |Can Opener | |
|Other: | |Trash can | |
|Toiletries: | |Garbage bags | |
|Razor | |Towels | |
|Soap | |Sheets | |
|Shampoo | |Blanket | |
|Toothpaste/denture cleaner | |Pillow | |
|Deodorant | |Toilet paper | |
|Furniture: | |Clock | |
|Bed | |Other: | |
|Kitchen table | |Groceries* | |
|Chair | |Miscellaneous Items (explain below) | |
|Sofa | | |
|Other: | | |
| |
|NAME OF THE PERSON REQUESTING THE FUNDS |DATE |
| | |
*Note: Food pantries, churches, and other sources of obtaining food should be considered before requesting funding for groceries. This category is limited to basic food needs and is a one-time only expense.
Please submit this form via fax to the Bureau of Home and Community Based Services at 573/522-3024. Program Unit staff will notify you at time of approval, adjustment, or denial of requested funds.
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