IM-7 - Missouri Department of Social Services



[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|AMOUNT WITHDRAWN | | | | | |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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