Form Mo 886-2848 - Im-2 Recording Worksheet - Missouri Department Of Social Services

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MISSOURI DEPARTMENT OF SOCIAL SERVICES
DIVISION OF FAMILY SERVICES
IM-2 RECORDING WORKSHEET
S
CASE NAME
DCN
ADDRESS
AUTHORIZED REPRESENTATIVE
N/A
SSN
CE
DISQ
MONTH
BIRTHDATE/
SSN-1
VERIFIED?
ELIG.
HOUSEHOLD/ASSISTANCE GROUP
MEMBER
DISQ
IM
FS
OR AGE
DATE SENT
CODE
ENDS
YES
NO
YES NO
A. ELIGIBILITY FACTORS
B. ADDITIONAL RECORDING
1. CITIZENSHIP/RESIDENCE/IDENTITY:
CITIZENS
ELIGIBLE LEGAL ALIEN
NAME ____________________________________ STATUS __________
ALIEN NOT ELIGIBLE
NAME ____________________________________ STATUS __________
RESIDENT OF MISSOURI
YES
NO
INTENDS TO REMAIN
YES
NO
IDENTITY VERIFIED BY: ________________________________________________
2. RESOURCES:
CASH ON HAND
BANK
IM-7 RECD
BANK
IM-7 RECD
OTHER
VEHICLES (RECORD FOR EACH CATEGORY OF
ASSISTANCE)
AVAILABLE PERSONAL PROPERTY
IM-8 RECD _______
AVAILABLE REAL PROPERTY
INSURANCE CO. ____________
IM-9 RECD _______
INSURANCE CO. ____________
IM-9 RECD _______
INSURANCE CO. ____________
IM-9 RECD _______
BURIAL:
FUNERAL HOME ____________
IM-9 RECD _______
IRREVOCABLE/REVOCABLE
TOTAL RESOURCES CONSIDERED
3. TRANSFER OF PROPERTY OR RESOURCES:
YES
NO
4. LIFE/HEALTH INSURANCE:
TPL-1
IM-37
NO INSURANCE
DATE/UPDATED ____________________________________________________
5. PRIOR QUARTER/PRIOR MONTH (GR):
YES
NO
IF NO, EXPLAIN IN SECTION B
PAGE 1
MO 886-2848 (3-01)
IM-38 (3-01)

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