IM-7
[pic] |MISSOURI DEPARTMENT OF SOCIAL SERVICES
FAMILY SUPPORT DIVISION
FINANCIAL INFORMATION REQUEST | | |
DATE
06/17/2005[pic]05/05/2004 | |
|COUNTY OFFICE |CASE NAME |
| | |
|ADDRESS |CASE NUMBER |
| | |
|CITY, STATE, ZIP |ADDRESS |
| | |
|PHONE | |
| - - | |
| | |
|FINANCIAL INSTITUTION NAME |CASEWORKER |
| | |
|ADDRESS |LOAD NO. |
| | |
|INSTRUCTIONS TO FINANCIAL INSTITUTION |
|We are determining eligibility or completing an assessment of assets in the above referenced case. We have provided the social security numbers, names and known |
|account numbers for members of the case. This request is for financial information on all accounts of these persons. A self-addressed stamped envelope is |
|enclosed for your convenience. |
|AUTHORIZATION FOR RELEASE OF INFORMATION |
|HEAD OF HOUSEHOLD/PAYEE NAME |SOCIAL SECURITY NO. |SIGNATURE |DATE SIGNED |
| | - - | | |
|SPOUSE/OTHER JOINT OWNER |SOCIAL SECURITY NO. |SIGNATURE |DATE SIGNED |
| | - - | | |
|NAME |SOCIAL SECURITY NO. |SIGNATURE |DATE SIGNED |
| | - - | | |
|FINANCIAL INFORMATION REQUESTED |
|Please provide information for the account numbers listed and any other Checking Accounts, Savings Accounts, Certificates of Deposit, Christmas Funds. Trust |
|Accounts, any type of Individual Retirement Accounts, or other accounts of the persons named above. |
| | | | | | |
| | | | | | |
|ACCOUNT NUMBER | | | | | |
| | | | | | |
| | | | | | |
|TYPE OF ACCOUNT | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|NAMES ON ACCOUNT | | | | | |
|CURRENT BALANCE | | | | | |
|IF 0, ENTER DATE CLOSED AND | | | | | |
|AMOUNT WITHDRAWN | | | | | |
| | | | | | |
|BALANCE AS OF | | | | | |
| | | | | | |
| | | | | | |
|AMOUNT OF | | | | | |
|INTEREST EARNED | | | | | |
| | | | | | |
| | | | | | |
|DATE INTEREST PAID | | | | | |
| | | | | | |
| | | | | | |
|PERIOD COVERED | | | | | |
| | | | | | |
| | | | | | |
|INTEREST RATE | | | | | |
|DIRECT DEPOSIT REQUEST Please make my assistance payment by direct deposit to my (checking) (savings) account. |
|DIRECT DEPOSIT |
|NAME TYPED |SIGNATURE |DATE |
| | | |
|BANK OFFICIAL Please enter transit routing number, account number and type of account for direct deposit below: |
|TRANSIT ROUTING NUMBER |ACCOUNT NUMBER |TYPE OF ACCOUNT |
|CHECK AND GIVE DETAILS ON BACK IF ANY OF THE ABOVE LISTED PERSONS HAVE ANY OF THE FOLLOWING |
| LARGE WITHDRAWALS SAFE DEPOSIT BOX LOANS OWED STOCKS BONDS TRUST |
|DEEDS OWED |
|ANY ADDITIONAL INFORMATION OR COMMENTS CONCERNING INVESTMENTS OR OTHER TRANSACTIONS WHICH YOU MAY HAVE HAD WITH THE ABOVE PERSONS WILL BE APPRECIATED. PLEASE LIST|
|ON BACK OR ATTACH SEPARATE SHEET. |
|SIGNATURE OF PERSON COMPLETING FORM TITLE |TELEPHONE NUMBER |DATE |
|MO 886-0684 (10-98)/E 05-2004 |PERMANENT (IM-7) |
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