Im-31aelec



MISSOURI DEPARTMENT OF SOCIAL SERVICESFAMILY SUPPORT DIVISIONREQUEST FOR INFORMATION FROMCOUNTY OFFICE FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ?????DATECOUNTY OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE) FORMTEXT ?????TONAME FORMTEXT ?????Head of Eligibility Unit FORMTEXT ?????ADDRESS (STREET) FORMTEXT ?????DCN FORMTEXT ?????Head of Eligibility Unit DCN CITYSTATEZIP CODE FORMTEXT ?????PROGRAMMO HealthNet for Families Prior Quarter Coverage RequestThe 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 FORMTEXT ?????.PROOF OF:Our records show that the following person(s) requested medical coverage in 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 agoFor which months does this person have unpaid medical bills? ? 3 months ago ? 2 months ago ? 1 month agoFor 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 agoFor which months does this person have unpaid medical bills? ? 3 months ago ? 2 months ago ? 1 month agoFor 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 agoFor which months does this person have unpaid medical bills? ? 3 months ago ? 2 months ago ? 1 month agoFor 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 agoFor which months does this person have unpaid medical bills? ? 3 months ago ? 2 months ago ? 1 month agoFor 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-31A PQ (02/2018) REQUEST FOR INFORMATION ContinuedHead of Eligibility Unit FORMTEXT ????? DCNProgram: MO HealthNet for Families Prior Quarter Coverage RequestPROOF OF: Household IncomeIncome 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 IMPORTANTIF YOU HAVE ANY QUESTIONS OR EXPERIENCE A DELAY IN SECURING ANY OF THE ABOVE ITEMS, CONTACT YOUR WORKER IMMEDIATELY:Eligibility Specialist FORMTEXT ?????Load FORMTEXT ?????Phone FORMTEXT ?????- FORMTEXT ?????- FORMTEXT ?????Fax FORMTEXT ?????- FORMTEXT ?????- FORMTEXT ?????IM-31A PQ (02/2018) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download