Missouri Department of Social Services Family Support Division
3. American Indian/Alaska Native
Social Security Number (if applying)
Are you or your spouse a party to a trust? Yes No If yes, we must review the entire trust. You must provide it and fill out below: Name and Date of Trust:
I/We have the following resources (include Trust assets you can access): check (
Someone in my house or I am self-employed:
Fill Out This Section If You Pay Any Child Support Or Alimony Payments
What state does the order come from?
NoIf no, fill out the following:
Enter The Address Or Location (for Mobile Homes, see personal property below)
How is it used? (Home, rental, Acreage, other)
Name of person with Long-term Care Insurance
2. Do you ask or beg for money?
3. Have you applied or do you agree to apply for Supplemental Security Income (SSI) as a condition of eligibility? 4. Have you had eye surgery within the last five years?