APPLICATION FOR TEMPORARY ASSISTANCE CASH BENEFITS

APPLICATION FOR TEMPORARY ASSISTANCE CASH BENEFITS

Temporary Assistance (TA) provides cash benefits to eligible families with children to help pay for basic needs.

  • By completing this application, you are applying for TA as a caretaker of a child
  • YOU MAY BE ELIGIBLE FOR CHILD CARE SUBSIDY TA recipients must participate in Work Requirements unless exempt. You can qualify for Child Care if you are participating. If you need Child Care you can apply by going to: https://dese.mo.gov/childhood/child-care-subsidy/families 
    • To apply online, click “Apply Online”
    • To print the paper application, click “Paper Application” (you can complete it online then print it, or print it and complete it by hand)

Need help with your application?

  • Call the Family Support Division (FSD) Call Center at 1-855-373-4636, or
  • Refer to Section 1 to find your local FSD Resource Center for in-person help
  • Need help in a language other than English?
    • Tell the customer service representative the language you need, or
    • See Section 7 “Language” for more information.
  • TTY users
    • Call 1-800-735-2966, or
    • Call Relay Missouri at 711
  • See “Other Helpful Numbers” in Section 1.

En español (Spanish) | ¿Necesita ayuda con su solicitud?

  • Llame al Centro de Atención de la División de Apoyo a la Familia (FSD) al 1-855-373-4636, o;
  • Consulte la sección 1 para localizar el Centro de Recursos de la FSD más cercano.
  • ¿Necesita ayuda en un idioma diferente al inglés?
    • Dígale al representante de servicio al cliente el idioma que usted necesita, o;
    • Consulte la Sección 7 “Idioma” (página 9) para obtener más información.
  • Usuario de TTY:
    • Llame al 1-800-735-2966, o;
    • Llame al servicio de Relay Missouri al 711.
  • Consulte “Otros números útiles” en la sección 1.

En bosnio (Bosnian) - Da li trebate pomoć sa Vašom aplikacijom?

  • Pozovite Centar za podršku porodici (FSD) na broj 1-855-373-4636 ili
  • Pogledajte odjeljak 1 na 4-oj stranici gdje možete pronaći vaš lokalni FSD Resurs Centar (Resource Center)
  • Da li Vam je potrebna pomoć na jeziku koji nije engleski?
    • Recite predstavniku servisa za kupce koji Vam je jezik potreban ili 
    • Pogledajte odjeljak 7 na 9-oj stranici gdje piše „Jezik”, za više informacija.
  • TTY korisnici
    • Pozovite 1-800-735-2966 ili
    • Pozovite Relay Missouri na 711
  • Također možete vidjeti i “Druge korisne brojeve” u odjeljku 1 na 4-oj stranici

En vietnamita (Vietnamese) - Quý vị cần được trợ giúp về việc hoàn thành mẫu đơn yêu cầu?

  • Vui lòng gọi đến Trung tâm Tiếp nhận Cuộc gọi của Ban Hỗ trợ Gia đình (Family Support Division (FSD)) theo số 1-855-373-4636 hoặc
  • Vui lòng xem Mục 1 để tìm Trung tâm Tài nguyên của FSD nơi Quý vị cư ngụ.
  • Quý vị cần được trợ giúp bằng một ngôn ngữ khác ngoài Tiếng Anh?
    • Xin hãy nói chuyện với đại diện dịch vụ khách hàng về ngôn ngữ Quý vị cần hoặc
    • Vui lòng xem Mục 7 “Ngôn ngữ” để biết thêm thông tin chi tiết.
  • Người dùng TTY
    • Vui lòng gọi đến số 1-800-735-2966 hoặc
    • Gọi cho Đường dây Chuyển tiếp Cuộc gọi của Tiểu bang Missouri theo số 711
    • Vui lòng xem “Các Số Hữu Ích Khác” trong Mục 38.

Please read and complete the “TA Orientation” Section 26, and the “Personal Responsibility Plan” Section 27. If they are not completed, this will delay the processing of your application and may cause your application to be REJECTED.

YOU MUST - Read and complete pages and you MUST SIGN “Your Agreement and Signature” Section 35.

PAPERWORK NEEDED - Many sections will provide information in BOLD print. This is to tell you about paperwork needed as proof of the information you put on your application, such as bank statements, birth certificates, paystubs, etc.

  • If you do not have the needed paperwork for each section your application cannot be fully processed until FSD receives everything.
  • If you do not provide all of the necessary paperwork, FSD will send you a “Request for Information” form detailing what paperwork you can provide and when it is needed. You may also receive an “Authorization for Release of Information” form(s). Then, you can either:
    • Send the requested paperwork and “Request for Information” form to FSD, or
    • Sign and send the “Authorization for Release of Information” form giving FSD permission to get the requested paperwork for you. It is your responsibility to make sure the paperwork is received by FSD.

ADDITIONAL SECTIONS - You may need to complete these added sections: 

  • If you have custody and control of one or more children and the other parent(s) are non-custodial, meaning they do not live with you and are not deceased, you MUST complete the following for each non-custodial parent of each child you include on your TA application:
    • Section 37 “Child Support Agreement,” and
    • Section 38 “Referral/Information for Child Support Services”
    • You may request more copies of the forms above if you need to list more than one non-custodial parent
  • If you choose to have your TA cash benefits directly deposited into your checking or savings account, complete:
    • Section 36 “Agreement for Direct Deposit” and provide a voided check, or have your bank complete Part III of the form

PROCESSING TIME - Your application will be processed within 30 days of your application date, unless you are missing information. Your application date is the date FSD receives your application within regular business/processing hours. If your application is received by FSD after regular business hours such as holidays, weekends or outside of regular operating hours, your application date is the next business day.

CHANGES TO OTHER BENEFITS - Information reported on your TA application will update any active case you have for Child Care Subsidy, Supplemental Nutrition Assistance Program (SNAP) also known as Food Stamps and/or MO HealthNet (Medicaid) programs. Therefore, if you have changes in income, resources, household members, etc., this can cause the benefit amounts for these other programs to change.

BENEFIT PAYMENTS - If approved for TA cash benefits, your first payment will be:

  • A partial month of benefits if FSD approves the application in the same month you apply, or
  • A full month of benefits if FSD approves the application the month after you apply.

HEARING RIGHTS - If you disagree with FSD's decision, you may ask for a hearing. For information on hearings, see “Important Information about Your Hearing Rights” in Section 34.

LIFETIME LIMIT - TA Cash Benefits has a 45-month lifetime limit

  • For teen parents under age 18 and in secondary (high) school, the months do not count toward the lifetime limit until you reach age 18.
  • TA benefits may be paid for longer than the lifetime limit if a participant is: 
    • Receiving treatment or services for domestic violence or substance abuse
    • Diagnosed and receiving treatment for mental health needs
    • Cooperating with the Children's Division open treatment plan and MWA job training program
    • In a temporary family crisis, such as a home fire, crime victim, company layoff, or serious injury.

To find your local Family Support Division (FSD) Resource Center or MWA office: 

  1. Go to: https://dss.mo.gov/offices.htm
  2. Enter your zip code and click Submit 
  3. Then scroll down and view the map with options to check for: 
    • FSD Resource Centers 
    • Missouri Work Assistance Centers (MWA) 
    • Food Pantries 
    • Community Action Agencies (CAA) Centers

FSD Information Center 

855-FSD-INFO (855-373-4636) 

Speak with a team member about FSD services, what benefits may be available to you and/or assistance with your application. 

To complete an interview 855-823-4908 

 

FSD Automated Information Line 

800-392-1261 

Check the status of your assistance application. You will need your Social Security Number and date of birth when calling. 

HOURS: Answered 24 hours a day 7 days a week

Other Helpful Numbers:

Child Support: https://dss.mo.gov/child-support/

Rehabilitation Services for the Blind: 800-592-6004

Relay Missouri: 711 (Information line if you are hearing and/or speech impaired)

Text Telephone: 800-735-2966

TTD Voice Access: 800-735-2466

Applicant full legal name – FIRST, MIDDLE, LAST (current and maiden last name)

Physical Address - Enter house or apartment number, street or county road, city, state and zip code

Homeless Applicants only - General delivery address – enter post office name, city, state and zip code

Mailing Address - Enter PO box, house or apartment number, street or county road, city, state and zip code

*Texting/Email is not available in all locations.

Household members living with you must include YOURSELF AND PEOPLE WHO LIVE IN YOUR HOME. Include all household members who are related to you or your child(ren) either by blood or marriage.  As the applicant, you must be either the parent, legal guardian, conservator, or related to the child(ren) in need of assistance in the home. You must also apply for benefits for any other household members who are in your care, custody, and control.

Do Include: Spouse, Parent of child(ren) for which you are applying, Father, Mother, Sister, Brother, Grandfather, Grandmother, Uncle, Aunt, Nephew, Niece, First Cousin, Stepfather, Stepmother Stepbrother, Stepsister, Legal Guardian

Do NOT include: Children age 18 who are not in secondary (high) school, children age 19 and over, or unrelated friends that are not a legal guardian.

Joint Custody: If you have joint legal or physical custody of any child(ren) listed in your household, you must list the other parent as a household member on the “Members of your Household Section” Section 3 and mark them as “J” under “Applying for this member or Joint custody member.”

Social Security Number (SSN): Since you are applying for TA, you must provide a SSN for you and every household member who is included in the household.

  • Federal law requires you give a Social Security number (SSN) for anyone who wants to get Temporary Assistance. (42 U.S.C. § 1320b-7; 42 U.S.C. § 405(c)(2)(C), 7 U.S.C. §§ 2011-2036, and Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369).
  • Any member of your household (including you) that does not have a SSN and are legally able to get a SSN, must agree to apply for a SSN or that household member will not qualify for TA.
    • We will refer you to a Social Security office to apply for a SSN or
    • You can apply for a SSN online at ssa.gov. You can fill out and print an application for a Social Security Card.
  • Immigrants who are not legally able to get a Social Security number are not required to give one or apply for one.
  • If you are not applying for benefits for yourself, you do not have to give us your Social Security number. However, it may reduce the total amount of Cash Assistance benefits for the person you are applying for because we will not include you in the benefit amount.
  • We will not use your SSN as your Department Client Number (DCN) identification number.
  • We will not give any SSN to the United States Citizenship and Immigration Services (USCIS).
  • We use your information, including SSN, to:
    • Verify identity
    • Verify citizenship and immigration status
    • Verify income and resources
    • Prevent duplicate benefits
    • Establish and enforce child support
    • Computer match with state, local and federal agencies and our other programs to verify information
    • Collect money if we overpay you any benefits
    • Share with other government agencies and their contractors to assess Cash Assistance   

We may give your information to law enforcement officials for the purpose of arresting persons fleeing to avoid the law.

IMPORTANT information on citizen and immigration status:

  • To get the most help, you need to give us information about citizenship and immigration status for each person who is applying for help.
  • Giving us the citizenship and immigration status for all people who are eligible for benefits allows us to include them in the Temporary Assistance benefit amount. If you do not give us this information, the total TA benefit amount for your household may be lower. However, it will not affect the eligibility of the people you are applying for who have given us verification of their citizenship or qualified non-citizen status.
  • You do not need to give us information about citizenship and immigration status for any person who is not applying.
  • You do not need to give us information on income, resources, or other information for those who have not given us citizenship or immigration status information to complete the application process.
  • If you are not applying for any benefits yourself or if you choose not to provide citizenship or Immigration information, we will not try to find out this information from USCIS.
  • Citizenship information will be completed in Section 20.

How to complete Members of your Household Chart below:

  • Member name - Name of person living in your place of residence - List yourself first and then each member of the household. If you have joint 50/50 custody of any children in your household, you need to list the person you have joint custody with as a member of your household even though they are not living with you. This person will be marked as a Joint custody member.
  • Race - Enter: 1 for White, 2 for Black/African American, 4 for American Indian/Alaska Native, 4A for Federally recognized Tribe, 5 for Asian, 6 for Native Hawaiian/Pacific Islander, or 7 for Other 
  • Sex: M for Male, F for Female
  • Legal Relationship to You - by marriage, blood, or court, (example: spouse, son, daughter, legal guardian)
  • Marital Status - Enter: SGL for Single, M for Married, D for Divorced, W for Widowed, SEP for Separated 
  • Date married, divorced, separated, or widowed - enter the date of your marital status change
  • Date of Birth for this member
  • Applying for this member or joint custody member:  Y for Yes, N for No, J for Joint Custody (if this is the other parent that shares joint custody with you but does not live with you)
  • SSN (Social Security Number) - Provide member's Social Security number if they have one
  • Will Apply for SSN - Enter Y for Yes, N for No (only complete if the household member does not have a SSN)

Select your race, the options are White, Black or African American,  American Indian or Native Alaskan, Federally Recognized Tribe,  Asain,  Native Hawaiian or Pacific Islander, and Two or more races. 

Select your race, the options are White, Black or African American,  American Indian or Native Alaskan, Federally Recognized Tribe,  Asain,  Native Hawaiian or Pacific Islander, and Two or more races. 

The FSD asks these questions in order to identify victims so these individuals can receive benefits and resources appropriate for their situations and ensure confidentiality of personal information and documentation.

The FSD asks these questions in order to share information and provide assistance to military-connected Missourians.

If yes, complete this section:

By appointing an authorized representative, you are consenting to allow FSD to send letters and notices to your authorized representative. The person you appoint must be age 18 or older and know your situation well enough that they can complete your application or act on your behalf. They will not knowingly make a false or misleading statement, hide information, or fail to report any fact or event that is required to be reported by any law, regulation or rule of this State or the United States.

I/we authorize this person (over the age of 18) to be responsible for (check one or more boxes):

Authorized Representative's Full Legal Name (First, Middle, Last)

Authorized Representative's Mailing Address - Enter House or Apartment Number, Street or County Road, City, State and Zip Code

I/we understand that I/we am responsible for the information given by my/our authorized representative, including any information that may be incorrect.

  • You must use your TA cash benefit to help your child or children.
  • Your TA cash benefit payment may be sent to you on an electronic benefit transfer (EBT) card or by direct deposit into a bank account. If you are approved for TA and your direct deposit isn't set up for the first payment, the first check will be mailed to you.
  • You may not use your EBT card in:
    • Liquor stores
    • Casinos, or gaming establishments
    • Retail establishments that provide adult-oriented entertainment, and 
    • Any places or for any items that are used by adults 18 or older and are not in the best interest of the child or household.

TA Benefit Misuse is Illegal:

  • Your EBT transactions will be monitored. 
  • If you misuse your TA money, you may be investigated and have to repay the money.
  • You are breaking the law if you buy someone else's EBT card or payments, or sell your EBT card or payments.

TA Benefit Payment Method:

  • Below, tell us how you want to get your TA cash benefit payment if you are approved for TA. If you are choosing Direct Deposit, complete the Direct Deposit Application Form in Section 36 (page 26) of this application.

Answer The Following:

Direct Deposit Information (complete section 36 on page 26):

It will take at least 10 days to verify your bank account.

  • Any payment made before the bank verifies your account will be by check mailed to you or by electronic benefit transfer.
  • The payment is transferred to your bank on the date that checks are mailed for your type of assistance. If you have a question about whether a payment has been credited to your account, you can get this information from your bank.
  • If you need to change your direct deposit bank account, you can contact the Family Support Division Customer Service at 855-373-4636. Immediately request that the direct deposit to the current bank account be stopped. If you do not do this, your payment will be delayed.
  • Any payment made after your direct deposit account is closed will be in the form of a check mailed to you at your mailing address.

IMPORTANT  - Complete this section and cooperate with drug screening or treatment if you want to get and keep TA benefits

This section includes important information on drug screening and treatment. Non-cooperation with this section can cause you to be ineligible for TA for a period of 3 years!

  • Missouri law requires FSD to ask TA applicants questions about illegal drug use.
  • If you refuse to answer these questions, you are INELIGIBLE FOR TA FOR 3 YEARS. You may ask for a hearing if you disagree.*
  • You may be required to take a drug test 
    • You will receive a letter from the drug testing company telling you where and when to take your drug test.
    • If you do not show up for the appointment, do not have all the required paperwork as requested at the time of your drug test or do not complete the drug test, you will be INELIGIBLE FOR TA FOR 3 YEARS. You may ask for a hearing if you disagree.* 
  • You can go directly to substance abuse treatment instead of taking a drug test.
    • If you are using illegal drugs, you can agree to go to treatment right away if you answer “Yes” to question #2 in the “Drug Screening” section below.
    • If you are approved for TA, your benefits will not be reduced because of drug screening requirements if you are complying with the substance abuse treatment requirements under the Department of Mental Health (DMH).
  • If you test positive:
    • You must agree to join, participate, and successfully complete a substance abuse treatment program through the DMH or you will be INELIGIBLE FOR TA FOR 3 YEARS. You may ask for a hearing if you disagree.*
    • If you are approved for TA, your benefits will not be reduced because of drug screening requirements if you are complying with the substance abuse treatment requirements under the DMH.
  • If you are referred to a drug treatment program:
    • The DMH will contact you to assess your need for treatment.
    • If you do not show up for treatment or do not complete the treatment, you are INELIGIBLE FOR TA FOR 3 YEARS. You may ask for a hearing if you disagree.* 
    • If you are approved for Temporary Assistance, your benefits will not be reduced because of drug screening requirements if you are complying with the substance abuse treatment requirements under the DMH.
  • If you are ineligible for TA, you must tell FSD who your Protective Payee is
    • You must choose a person to receive the TA benefit for the rest of your household. This person is called a “protective payee”. If you do not choose a protective payee, FSD will choose this person. You may ask for a hearing if you disagree.*

*See Section 34 for “Important Information about your Hearing Rights”.

Drug Screening  - Answer the Following:

Ongoing Drug Test Referrals

  • If you are approved for TA and are age 18 or older and head of the household, your name will be matched with records from the Missouri Highway Patrol (MHP).
    • The FSD will send your name to the MHP so the MHP can match your name with their records.
    • MHP will send FSD information on drug-related arrests or convictions within the last 12 months.
    • If you had a drug related arrest or conviction, your name will be sent to a drug testing company.
    • The drug testing company will send you a letter telling you where and when to take your drug test.
    • If you do not show up for the appointment or do not complete the drug test, you are INELIGIBLE FOR TA FOR 3 YEARS. You may ask for a hearing if you disagree. See Section 34 for “Important Information about your Hearing Rights”.

The FSD needs to know information on the language you speak to better help you. The language you speak will not impact your ability to receive TA benefits.

If no, what language do you speak?

If Yes, list below. If this applies to you, start with yourself first.

If Yes, list below. If this applies to you, start with yourself first.

If Yes, list below. If this applies to you, start with yourself first.

If Yes, complete for each household member. If this applies to you, start with yourself first.

Resources (such as checking account) must be proven to process your application. If you have this information, provide it with this application. If you don't have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received by FSD.

If Yes, complete for each household member. If this applies to you, start with yourself first.

Burial plans must be proven to process your application. If you have a copy of the burial plan with the policy owner, insurance company name (if any), insurance policy number (if any), plan face value and plan benefit surrender value, provide it with the application. If you don't have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received by FSD.

If Yes, complete for each household member. If this applies to you, start with yourself first. If a household member has more than one job, list each job on separate lines.

We must have proof of employment to process your application. If you have a copy of paycheck stubs within the last 30 days, provide them with the application. If you don't have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received by FSD.

If Yes, complete below. If No, skip to section 13. 

We must have proof of self-employment to process your application. If you were self-employed for the entire year from Jan - Dec you can provide your most recent tax return. If you have not been self-employed for the entire year you can provide business ledgers, receipts, business account records, references etc. and provide them with the application. If you don't have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received by FSD.

  • The below ledgers must reflect income for the self-employment for the last 3 months.
  • The income recorded should be the same as what is required to be reported for the household member on your tax forms sent to the Internal Revenue Service (IRS).
  • You must indicate the month, year, gross income, total expenses and type of expenses. (you will be required to provide proof of this information).

List of other Income:

Child Support

Social Security  - Enter claim number:

Supplemental Security Income (SSI), 

Social Security Disability Income (SSDI), 

Old Age, Survivor and Disability Insurance (OASDI) 

Employer Sponsored Disability Payments

Trust Fund/Annuities                            

Interest or Dividends                             

Pension/Retirement/Disability

Veteran's Benefits

Unemployment Compensation             

Money from friends or relatives

Other  - Describe what other income you may have

If Yes, complete for each household member. If this applies to you, start with yourself first.

  • Other income must be proven to process your application. If you have any of the papers listed below, provide them with your application. If you don't have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received by FSD.
    • Trust Funds/Annuities and Pensions/Retirements - Award letter or statement from the plan showing the monthly income amount.
    • Veteran's Administration (VA) benefits - VA letter with the current benefit amount.
    • Money from friends or relatives - A written statement from the person who gave the money.

If yes, complete below for each household member. If this applies to you, start with yourself first. 

In this section answer "yes" for anyone tried as an adult or who had a trial scheduled. If the answer is "Yes" list all household members this applies to. If the question does not apply to anyone in the household answer "No".

Complete below for each household member, start with yourself first. List this in the same order as the “Members of Your Household” in Section 3. If the household member was born in Missouri, FSD may not need additional information. If you have birth certificates for household members not born in Missouri, provide these with your application. If you don’t have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

If no, list each household member’s name who isn’t a Missouri resident or doesn’t plan to stay. If this applies to you, start with yourself first.

List of reasons that a member may be out of the home:

In Children's Division custody

In treatment facility

In trial home placement with Children's Division

In hospital

In Job Corps

Temporarily out of state

In school

Other - describe

If Yes, complete for each household member. If this applies to you, start with yourself first.

Complete below for yourself and anyone in the household who is attending school, including children who were required to start kindergarten or are age 6 or over. Start with yourself first. For household members who are 17 or older and in high school, provide letter from the school showing the student is enrolled, the student’s status and expected graduation date. If you don’t have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

  • If no, complete the Immigration Status below for each household member who is not a United States Citizen. 
  • If you are not a United States Citizen, your TA eligibility depends on if your citizenship status is qualified or non-qualified and your date of entry into the US.
  • Certain qualified non-United States citizens are ineligible for 5 years from their date of entry.
  • Do not complete for any household member who you are not applying for.

Citizenship status must be proven to process your application. If you have any of these documents listed below provide a copy with your application. If you don’t have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

  • Birth Certificate  
  • Certification Letter 
  • DD214 
  • Military ID
  • Letter from the Canadian Dept. of Indian Affairs
  • Order of an Immigrant Judge 
  • USCIS or Homeland Security Paperwork Indicating Alien Status 
  • Other (explain)

Immigration status for these Household members

If Yes, complete for each household member who has these conditions. If you are disabled, start with yourself first.

Some of the disabilities listed below provide information in bold that you can use to provide proof of your disability. If you don’t have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

List of Disability Types:

  • Blind
  • Pending Disability - Supplemental Security Income (SSI); Social Security Disability Income (SSDI); Old Age, Survivor and Disability Insurance (OASDI) or Employer Sponsored Disability payments
  • Receives MO HealthNet for the Aged, Blind and Disabled
  • Receives Social Security Disability
  • Receives SSI
  • Have Not Applied for Disability, but I am Disabled. You must also complete the MO HealthNet application at http://dss.mo.gov/mhk/appl.htm and apply for SSI or SSDI at ssa.mo.gov.
  • Receives Supplemental Aid to the Blind
  • Employer Sponsored Disability Insurance  - If you have a statement from your insurance provider dated within the last 30 days, provide it.
  • Needed in the Home to Care for a Disabled Individual  - If you have a statement from a medical professional indicating the Individual requires you to stay home with them, dated within the last 30 days, provide it. 
  • Receives Railroad Disability Benefit - If you have a statement dated within the last 30 days, provide it.
  • Temporarily Disabled - If you have a medical professional statement dated within the last 30 days indicating the duration of the temporary disability, provide it.
  • Veteran with any Rate of Disability - If you have a medical professional statement dated within the last 30 days, provide it.

If Yes, complete for each household member this applies to.

If this applies to you, start with yourself first. If you have a copy of paycheck stubs within the last 30 days, provide them with the application. If you don't have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

TA applicants are REQUIRED to complete Child Support forms. Do not complete these forms if both parents of the child(ren) are living in the same house.

If you have custody and control of one or more child(ren) and the other parent(s) do not live with you and are not deceased, you MUST complete the following for each non-custodial parent of each child you include on your TA application:

  • “Child Support Agreement” in Section 37 
  • “Referral/Information for Child Support Services” in Section 38 
  • You may request more copies of the forms above if you need to list more than one non-custodial parent. To request these forms, call 855-FSD-INFO (855-373-4636) or visit your local FSD Resource Center. Refer to Section 1 to find your local FSD Resource Center.

Section 26 SUBSIDIZED HOUSING

  • Subsidized housing includes local, state, or federal government payments for all or part of the household's housing costs.
  • Examples of HUD housing include
    • Section 8
    • Privately owned subsidized housing 
    • Public Housing

TAKING PART IN WORK TRAINING IS REQUIRED if you want to get and keep TA benefits

To be eligible for TA benefits, each parent of the child needing assistance and living in your household must take these actions:

  1. Complete and send or drop off your TA application, including sections 25 and 26:
    • Read and sign the TA Orientation in Section 26, If you would rather watch the TA Orientation video, go online to http://dss.mo.gov/fsd/tempa.htm. If you view the orientation video online you still MUST sign Section 26 "TA Orientation".
    • Read and sign the Personal Responsibility Plan (PRP) in Section 27 listing the activities you agree to participate in.
    • Include both of these signed Sections (25 and 26) as part of your TA application when you send it or drop it off.
  2. Register or sign in for work training – the sooner, the better. Before we can process your TA application, you must:
    • Register online at www.jobs.mo.gov
    • If you are already registered, sign into your account at www.jobs.mo.gov
    • Print your login page with your name on it to provide us with proof you have registered and signed into your account.

If you do not carry out the actions listed above, your TA APPLICATION WILL BE REJECTED. You may ask for a hearing if you disagree.

About the work training program, Missouri Work Assistance (MWA):

  • You will have required participation hours
    • If you are approved for TA, you will be required to participate in work and training activities for a set number of hours per week, which will be averaged for the month.
    • These requirements will be explained to you when you meet with a Missouri Work Assistance (MWA) case manager.
  • Participate to keep your benefits
    • If you do not participate in work and training activities and you do not have "good cause" to be exempt:
      • First, your TA BENEFIT WILL BE LOWERED BY 50%
      • Then, if you do not participate after benefits are lowered by 50% (cut in half), your TA CASE COULD CLOSE.

You MUST read or view the TA Orientation and sign at the end of this section. You can read the written version below or go to http://dss.mo.gov/fsd/tempa.htm to view the orientation video. If you have questions, call FSD at 1-855-373-4636 or visit an FSD Resource Center. See contact information listed in Section 1.

Temporary Assistance Orientation

Welcome to the Department of Social Services’ Family Support Division’s Temporary Assistance Orientation. The Family Support Division, which is referred to as FSD, handles the Temporary Assistance for Needy Families program in Missouri. The FSD can also help you with SNAP, Child Care and MO HealthNet medical coverage. Missouri Work Assistance, also referred to as MWA, is FSD’s partner. MWA provides employment and training services for Temporary Assistance recipients. MWA has location employment and training services for Temporary Assistance recipients. MWA has locations all over the state. To get a list of MWA locations and hours go to https://dss.mo.gov/mwa or call 855-373-4636.

Temporary Assistance Purpose

Temporary Assistance gives low-income families with children a monthly cash payment. Only parents, relatives, or legal guardians taking care of children qualify for Temporary Assistance. This Orientation will explain how the Temporary Assistance program works. Your eligibility will be determined by FSD. Eligibility requirements are subject to change.

Temporary Assistance Lifetime Limits

You can get Temporary Assistance benefits for 45 months in your lifetime. Below are situations where benefits may be extended past 45 months:

  • Receiving treatment or services for domestic violence or substance abuse
  • Diagnosed and receiving treatment for mental health needs
  • Cooperating with the Children’s Division open treatment plan and MWA program
  • A temporary family crisis, such as a home fire, crime victim, company layoff, or serious injury

The following reasons will not extend benefits past 45 months:

  • You can't find a job or you don't want to work
  • Your unemployment ran out
  • You don't have a car

Work and Training

If you are approved for Temporary Assistance, the Missouri Work Assistance Program will help you transition from Temporary Assistance to a job by helping you set goals and get the skills you need to find a job and support your family. Your MWA case manager will explain the federal employment and training requirements and report the time you have spent in activities to FSD.

You may be exempt from work or training activities if you are:

  • A single parent of a child under 12 weeks
  • Permanently disabled or you are taking care of a disabled person who lives in your home
  • You are age 60 or older
  • In an emergency situation, including domestic violence

Even if you are exempt, work and training activities through MWA are not required, but you may take part if you would like to.

Individual Employment Plan

If you are approved for Temporary Assistance and not exempt, you will get a letter with a meeting date, time, and place to meet with a MWA case manager to develop an Individual Employment Plan.

The Individual Employment Plan:

  • Helps you list things that keep you from working or going to school, such as no access to childcare or transportation. Then, your case manager will help you work on a plan to solve these.
  • Lists the activities you will participate in, such as a job and training.
  • When you sign this plan you agree to take part in the activities for the required hours
  • If you need to make changes to this agreement, you must contact your MWA case manager right away.

Non-Participation in Work and Training Activities

After you and your case manager have agreed on your Individual Employment Plan, you must start participating in work and training activities OR your benefits can be lowered by half and then your case can be closed.

If you do not come to the meetings with your MWA case manager, your benefits will also be affected.

Your MWA case manager will explain this process more in depth. You must keep all appointments with your MWA case manager, or call before or within the same week of your appointment to reschedule.

Support Services

To help you take part in work and training activities, the MWA offers a  variety of support services including:

  • Help with transportation to work or school, and
  • Help with some work related expenses, like uniforms or emergency car repairs

If you NEED CHILD CARE to go to work and training activities, you should COMPLETE A CHILD CARE APPLICATION now to get help with the cost. 

You can find this application at:

https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-1cc.pdf or go to https://dss.mo.gov/dss_map/ to find your local FSD Resource Center. You can also call 855-373-4636.

Drug Screening

Missouri law requires FSD to ask Temporary Assistance applicants questions about illegal drug use. If you are approved for Temporary Assistance and you refused to answer these questions or go to substance abuse treatment, you are INELIGIBLE FOR TEMPORARY ASSISTANCE YOURSELF FOR 3 YEARS.

If at any time while receiving Temporary Assistance you are arrested, charged, or convicted for a drug related offense, you will automatically be required to take a drug test. If you test positive for illegal drugs, INELIGIBLE FOR TEMPORARY ASSISTANCE YOURSELF FOR 3 YEARS.

During those three years, the children’s money will be paid to someone else, called a Protective Payee, who must use the money for the children’s needs. If you are approved for Temporary Assistance and you are taking illegal drugs and you want help, FSD will find a substance abuse center for you to receive treatment.

Child Support

If you are approved for Temporary Assistance and the children have a parent who lives outside your home, FSD will automatically work to establish or collect child support for you. If you do not help FSD to either establish or collect child support, your Temporary Assistance will be cut by 25%.

If you are afraid this action would result in emotional or physical harm to you or the children, please indicate this concern in Section 36 of your application and you may not have to give information for FSD to collect child support.

Temporary Assistance Payment Methods

Temporary Assistance money is paid through an Electronic Benefits Transfer, or EBT card, or by direct deposit into your bank account. If you use your EBT card in any way that does not benefit the children, such as use your card at a liquor store, casino, or adult entertainment business, you must pay the money back to FSD.

Orientation Conclusion

When you apply for or receive Temporary Assistance:

  • You must tell the truth, provide proof and cooperate
  • You have rights as outlined in the application

This ends the orientation for the Temporary Assistance program. If you have questions:

  • Call FSD at 1-855-373-4636 or visit a Family Support Division Resource Center which can be found at the website listed in Section 1 of the Temporary Assistance application.

If you want to apply for Temporary Assistance, fill out the Temporary Assistance application and send it to FSD, or stop by your local FSD office.

By signing below, I am saying, under penalty of perjury, that I have viewed, read, or listened to the TA orientation. I understand that my signature below is not an application for TA, but a statement that I have completed the orientation.

Complete your name, county and school district, and the address information that applies to you.

FIRST PARENT (APPLICANT) FULL LEGAL NAME – FIRST, MIDDLE, LAST (Current and Maiden last name)

PHYSICAL ADDRESS – ENTER HOUSE OR APARTMENT NUMBER, STREET OR COUNTY ROAD, CITY, STATE AND ZIP CODE

HOMELESS APPLICANTS ONLY: ENTER GENERAL DELIVERY ADDRESS – ENTER POST OFFICE NAME, CITY, STATE AND ZIP CODE

MAILING ADDRESS – IF DIFFERENT FROM PHYSICAL ADDRESS – ENTER HOUSE OR APARTMENT NUMBER, STREET OR COUNTY ROAD, CITY, STATE AND ZIP CODE

*Texting/Email is not available in all locations

First parent (applicant) exemptions

If you believe you are exempt from work activities, you may be asked to provide proof that you are exempt.

You can volunteer to participate in work activities even if you are exempt. Mark the box below if you wish to volunteer:

Second parent (only if living with you) exemptions

If you believe you are exempt from work activities, you may be asked to provide proof that you are exempt.

You can volunteer to participate in work activities even if you are exempt. Mark the box below if you wish to volunteer:

If you are approved for TA and you do not meet an exemption, you will meet with an MWA program case manager who will talk to you about the activities you check below. During these meetings, you and your case manager may agree on other activities which are different than these choices. If you have questions about these activities, contact your local MWA office. To obtain a list of MWA locations refer to Section 1.

First parent (applicant) activities (choose one or more)

Second parent (only if living with you) activities (choose one or more)

I understand that, if I have not selected an exemption OR an employment and training activity for the first parent (applicant) and second parent (only if in home), I may not be eligible for Temporary Assistance. I understand there are times when the activity is either not available or I need to take part in other activities first.

I understand if I do not sign below, I may not be eligible for TA. By signing below, I am agreeing that I believe I either have an exemption or agree to participate in the work and training activities. I understand that my signature below is not an application for TA, but is an agreement to participate in work and training activities as part of receiving TA benefits.

If yes, complete below for each household member this applies to. If it applies to you, start with yourself first.

If yes, complete below for each household member this applies to. If it applies to you, start with yourself first.

List of Real Estate Types:

    Building and Land        Home and up to 40 acres of land        A lot(s)        Acreage        

    Home and over 40 acres of land

If yes, complete below for each household member this applies to. If it applies to you, start with yourself first.

List of Personal Property Types:

Aircraft

Business equipment or tools

Boat or Motor

Burial Plot

Camper or camper trailer

Farm machinery

Grain or produce or timber

Household furnishings not in use

Jewelry - not wedding rings

Livestock

Motor home

Trailer (utility, boat, etc.)

If Yes, complete for each household member this applies to. If this applies to you, start with yourself first. If you have a copy of a statement or letter from the life insurance company with the policy owner, insurance company name, insurance policy number, plan face value and plan benefit surrender value dated within the last 30 days, provide it. If you don’t have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

If Yes, complete for each household member this applies to. If this applies to you, start with yourself first. If you have a letter from the child care provider with the cost for the last month, provide it. If you don’t have this information, you will be asked to provide it at a later date. The FSD can help you get this information, but it is your responsibility to make sure the information is received.

  • Temporary Assistance Diversion provides a one-time payment that is equal to what you could receive in Temporary Assistance over two or three months.
  • TA Diversion is an option if you can support your family if an immediate need that prevents you from working is met. Such as money to fix your car.
  • You must be eligible for TA and meet specific conditions in order to receive a TA Diversion payment instead of TA.
  • If you receive a TA Diversion payment, you cannot receive TA for two or three months, depending on how much was issued for the diversion payment. You can only receive a TA Diversion payment one time every 12 months, and only 5 times in your lifetime.

Reason for TA Diversion payment (mark one or more)

  • You must report any changes to the information on this TA application within 10 days.
    • Examples include, but are not limited to: raising or lowering of a household member's income, employment changes, household member changes, etc.
  • It is your duty to report these changes, and you cannot wait until you are contacted. To report changes:
    • Go to a Family Support Division Resource Center, using the instructions listed in Section 1 OR
    • Report changes online at https://dss.mo.gov/ and click on "How to I Report Changes and Check Benefits", or Call 1-855-375-4636

Section 35 YOUR RESPONSIBILITIES AND RIGHTS

You must give true information and follow the law

  • Federal, state, and local officials have the right to check the truth of any information you give on your application.
  • You may be denied benefits and/or be charged with a crime if you knowingly give FSD false information.

Veteran's Benefits

  • If you are a veteran and you refuse to apply for Veteran’s benefits without good cause, you might be ineligible for TA.
  • To find the nearest office to apply, go to benefits.va.gov.

Child Protection Clause

  • If you are a single caretaker with a child under the age of 6, and you can't find child care, you cannot be sanctioned while finding child care. Your MWA case manager will discuss this with you further.
  • You must work on a plan to find this child care.

Hearing Rights

You have the right to a hearing if you have applied for or are receiving Temporary Assistance (TA), MO HealthNet, or SNAP Benefits, and the following happens:

  • The Family Support Division (FSD) decides that you are not eligible and you think you are.
  • The FSD provides you with TA, MO HealthNet, or SNAP benefits and then reduces or stops the benefits and you think this was done in error.
  • You disagree with the information used to determine the benefit amount or you disagree with the benefit amount.
  • The FSD refuses to take your application.
  • The FSD does not process your application within 30 calendar days, and you have either:
    • Provide the information in the "Request for Information" or
    • You have given FSD permission to request this information. 

Hearing Timeframe

  • If your application has been refused or rejected or the planned action has already been taken, you may request a hearing within 90 calendar days of the refusal or action.
  • If the proposed action will change or stop your benefits and you request a hearing within 10 days from the date of the notice, you may continue to receive the same benefits until the hearing decision. If you lose the hearing you will have to reimburse the state for any benefits that you were not eligible for.

Requesting A Hearing

You, or your representative, may request a hearing by phone, in-person, or in writing. You will be asked why you disagree with the action or proposed action on your case. This is the reason for the hearing.

  • To request a hearing by phone, contact FSD at 855-373-4636. An FSD team member will complete the hearing request form for you.
  • If you request a hearing in-person, an FSD team member will complete the form for you. You may request a form, and mail it back.
  • If you request a hearing in writing, FSD will complete the form for you and will enclose your written request.

You will be notified in writing of the date, time, and place for your hearing. You will be scheduled for a telephone hearing at your local FSD office. If there is a reason you cannot participate in a telephone hearing or are not available on the scheduled date, you will be instructed to contact the Administrative Hearings unit within FSD.

Preparing For A Hearing

A pre-hearing conference will be scheduled with a FSD supervisor. This does not replace the hearing. The FSD will give you copies of your case record and any information they used to arrive at the action. If you need more information from FSD, ask a FSD team member. The FSD team member will provide you as much information as possible.

You may be asked to provide information that supports your hearing request. You can choose not to provide this information but providing this may help you win the hearing. This information may include:

  • Medical records or a written statement from a doctor.
  • Proof of income or expenses or changes in income or expenses.
  • A witness who can verify your statements.

Write down the reasons for your hearing before the hearing and bring the list with you. This will make sure your concerns and questions are covered.

If you do not have an attorney or cannot afford one, you may be eligible for free legal services. The telephone number to inquire about free legal services is included in notices from FSD. If you do not have the number, call toll-free 855-373-4636.

The Hearing

There is no cost to you to have a hearing with FSD. The hearing is held in the local FSD office with the Hearings Officer on speaker phone.

  • You must be present at FSD Resource Center as indicated on your “Notice of Administrative Hearing” or make other arrangements with the Hearings Officer (i.e. you are homebound and cannot come into the office).
  • A Hearings Officer will preside over the hearing and will lead everyone through the process. The Hearings Officer will swear in all witnesses.
  • The FSD will present the reasons for their actions and documents to support the actions.
  • You and/or your representative will present the reasons you do not agree, including any facts and documents you have to submit.
  • The Hearings Officer will allow you time to question all witnesses and will question the witnesses to ensure all evidence is presented and discussed.

The Hearing Decision

  • You will be notified of the results of the hearing in writing by FSD.
  • The decision is based on the evidence and testimony presented at the hearing.
  • When the hearing decision results in a change in your benefits or if FSD changes its decision before the hearing, FSD will adjust your case.
  • You will receive a written notice of any changes to your TA case.
  • If you or your representative do not agree with the hearing decision, you have 90 days to request forms and appeal the decision to the Circuit Court. Instructions to request forms will be included with your hearing decision.

Hearing Questions and Answers

Can I change my mind after I requested a hearing?

  • Yes, you can change your mind. If you do not want the hearing, notify FSD. You will be asked to complete a form to withdraw your request.

Can FSD withdraw from a hearing?

  • Yes, FSD can withdraw from a hearing if they find that they have made an incorrect determination. You will receive a written notice of their action to withdraw from the hearing.

What if I cannot attend the scheduled hearing?

  • Contact the Administrative Hearings unit within FSD. The hearing may be rescheduled in some circumstances. If you do not attend, the decision may be in favor of FSD.

Can I continue to receive the same amount of benefits until the hearing decision?

  • Yes, in some cases you can receive the same amount of benefits until the hearing decision. You should discuss this with a FSD team member. If FSD is affirmed, any benefits you are not eligible for will need to be repaid to FSD.

Do I need a lawyer?

  • No, but you may have a legal representative if you choose. You may also represent yourself or have a friend or relative represent you.

Can I reapply while waiting for a hearing?

  • Yes, you may reapply at any time and continue to report changes on your case.

Civil Rights Law

In accordance with federal civil rights laws and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Programs that receive federal financial assistance from the U.S. Department of Health and Human Services (HHS), such as Temporary Assistance for Needy Families (TANF), and programs HHS directly operates are also prohibited from discrimination under federal civil rights laws and HHS regulations.



Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or who have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.



HHS provides federal financial assistance for many programs to enhance health and well-being, including TANF, Head Start, the Low Income Home Energy Assistance Program (LIHEAP), and others. If you believe that you have been discriminated against because of your race, color, national origin, disability, age, sex (including pregnancy, sexual orientation, and gender identity), or religion in programs or activities that HHS directly operates or to which HHS provides federal financial assistance, you may file a complaint with the Office for Civil Rights (OCR) for yourself or for someone else.



To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial assistance through HHS, complete the form on line through OCR’s Complaint Portal at https://ocrportal.hhs.gov/ocr/. You may also contact OCR via mail at: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; fax: (202) 619-3818; or email: OCRmail@hhs.gov. For faster processing, we encourage you to use the OCR online portal to file complaints rather than filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR at OCRMail@hhs.gov or call OCR toll-free at 1-800-368-1019, TDD 1-800-537-7697. For persons who are deaf, hard of hearing, or have speech difficulties, please dial 7-1-1 to access telecommunications relay services. We also provide alternative formats (such as Braille and large print), auxiliary aids and language assistance services free of charge for filing a complaint.



This institution is an equal opportunity provider.

You MUST write your initials after each of these statements and then sign the application agreeing that everything stated is true:

By signing this application on paper or electronically, I am giving FSD permission to deliver, or cause to be delivered, phone calls to me regarding my case from an automated dialing system at the main phone number you provided on page 

↓  SIGN HERE ↓   

5 WAYS TO GET YOUR TA APPLICATION TO THE FSD

  1. Apply Online at https://mydss.mo.gov/
  2. Mail the completed TA application with any information (such as paperwork) you have to:
    • Family Support Division
    • PO BOX 2700
    • Jefferson City, MO 65102
  3. Online: mydssupload.mo.gov
  4. You may also have the option of taking your completed TA application to an FSD Resource Center (REFER TO SECTION 1 on PAGE 4: To Find information, including availability and hours of operation, for your local FSD Resource Center or MWA office)
  5. Fax to: 573-526-9400

PART l

PART ll

PART lll

or

CUSTOMER: I wish to receive my cash benefit by direct deposit. I do not have a bank account now but intend to open one immediately. I understand direct deposit of my cash benefit will start once my account is open.

Who has to complete this form?

If you are providing care, custody, and control for a child or children and the other parent(s) does not live with you and is not deceased, you must complete this for each non-custodial parent of each child you include on your TA application. 

Child Support may help with:

  1. Finding the non-custodial parent;
  2. Establishing the child’s legal father through paternity;
  3. Getting support payments which may be higher than the Temporary Assistance (TA) payment;
  4. Obtaining medical support from the non-custodial parent for your child(ren).

Your Responsibilities Unless You Have Good Cause

The law requires you to help the Family Support Division (FSD) to get child support payments from the non-custodial parent for any child you applied for or who is receiving TA. The FSD may ask you to:

  1. Name the parent of the child that is not living with you and give information to help find the parent;
  2. Help legally determine who the father is if the child’s parents were not married when the child was born;
  3. Give information to get child support payments owed to you or the children for whom you are getting TA payments;
  4. Come to FSD Income Maintenance or Child Support office, court, and other locations to sign papers or give information or documentary evidence.

Penalty for Not Cooperating

  1. The Temporary Assistance benefit for you (the parent or caretaker) will be reduced by 25%.
  2. Your children will still be eligible for TA.

You May Have Good Cause

You may not have to cooperate in getting child support and medical support if you give proof that this would not be in the best interest of you or your child. You can claim “good cause” at any time. See the list of good cause reasons below.

How to Claim Good Cause

  1. Provide FSD with the evidence needed to determine whether you have good cause for refusing to cooperate.
  2. If your reason for claiming good cause is you fear physical harm and it is impossible to prove this, FSD may still be able to make a good cause determination after an investigation of your claim.
  3. You must check the “good cause” box located above the signature area on the next page.
  4. You must give proof to FSD within 20 days after claiming good cause. If you need more time, you must talk to FSD so they can determine if the additional time is needed to get proof.

GOOD CAUSE REASONS FOR NOT COOPERATING TO GET CHILD SUPPORT

EXAMPLES OF PROOF

This will cause serious physical or emotional harm to you or your child which would not allow you to take care of your child, or this will cause domestic violence.

  • Court, medical, law enforcement, psychological, and criminal records.
  • Child protective services and social services records.
  • Medical records with you or the child’s health history and present emotional health.
  • A written diagnosis or prognosis from a mental health professional indicating the emotional harm that could result to you or your child.
  • Sworn statements from individuals, including friends, neighbors, clergymen, social workers, and medical professionals who might have knowledge of the circumstances providing the basis of your good cause claim.

This will cause domestic violence.

  • A written statement will be accepted if no other proof is available.

Establishing the paternity or getting the support will harm you or your child because the child was conceived as a result of incest or forcible rape (this does not include statutory rape).

  • Medical or law enforcement records which indicate this information.

Establishing the paternity or getting the support will harm the child.

  • Court documents or other records to indicate legal adoption procedures are pending (waiting to be decided).

You are working with an agency helping you to decide whether to place the child for adoption and such help has been given for less than 3 months.

  • Written statements from public or private social agency (as recognized in the community) which state you are being helped by the agency to decide whether to keep the child or place the child for adoption and such help has been given for less than 3 months.

FSD'S Response to the Good Cause Report

  1. The FSD will approve your good cause based on your proof or conduct an investigation to verify your claim.
  2. If FSD conducts an investigation:
    • You may be asked to provide information.
    • The FSD will not contact the non-custodial parent without first telling you.
    • You will not receive your part of TA benefits until you have provided proof and any additional information requested.

Giving Child Support to the State

  1. When you sign the TA application, you are giving the State of Missouri all of your rights to child support and maintenance or alimony while you are receiving TA. The maximum amount of support that the State may keep is the amount paid to you in Temporary Assistance payments.
  2. When you assign your rights to the State, you may not make any agreement with the person who owes the support which would:
    • Change the duty to pay past child support owed to the state;
    • Affect the duty to pay current support;
    • Affect the duty to pay or the amount of future support; or
    • Affect the child support payments by paying for other things instead of paying the support. For example, you cannot agree to let the person who owes support make the house or car payment instead of the child support payment.
  3. If you are represented by a private attorney to collect child support for you:
    • You must advise the attorney that all money collected for current child support and arrearages (past due child support) owed to the State, will go to the State as long as the Assignment is in effect.
    • Should the State’s claim be fully satisfied, the State will send payments to you.
  4. If you are approved for TA and you receive any child support prior to the approval date, you must notify FSD within 10 days.
  5. If you are approved for TA and you are receiving support:
    • All child support must be sent to the Family Support payment Center the month following the month of your approval
    • Example: You are receiving child support payments when you apply for TA in October. If you are approved for TA in November, you must send all support received in December or after to the Family Support Payment Center.
  6. If you are approved for TA and you were not receiving child support payments when you applied, all future support must be sent to the Family Support Payment Center beginning with the first day of the month you will receive TA.
  7. When the state collects the support, you are no longer involved on the timeliness and amount of the payment.
    • If a parent is not making appropriate support payments, the State will take legal action to get the payment(s).
    • Your TA benefits are not impacted.
  8. If your support equals or exceeds your TA benefit, you will be notified and:
    • Your TA case will be closed
    • The State may collect and keep support that is past due to repay TA payments you received
    • The State will not keep any current support to repay TA payments

Child Support Agency Participation and Enforcement

  • Child Support may review FSD’s findings and the basis for a good cause determination in your case.
  • If you request a hearing regarding good cause, Child Support may participate in that hearing.
  • If you are found to have good cause for not cooperating, Child Support will not attempt to establish paternity or collect support.

I understand all 4 parts of this notice (section 37).

You must complete every item even if you have given information before. This form is used to take action on your child support case.

CUSTODIAL PARENT OR CUSTODIAN INFORMATION

Select your race, the options are White, Black or African American,  American Indian or Native Alaskan, Federally Recognized Tribe,  Asain,  Native Hawaiian or Pacific Islander, and Two or more races. 

NON-CUSTODIAL PARENT OR ALLEGED FATHER INFORMATION

Select your race, the options are White, Black or African American,  American Indian or Native Alaskan, Federally Recognized Tribe,  Asain,  Native Hawaiian or Pacific Islander, and Two or more races. 

CHILDREN OF THE CUSTODIAL PARENT AND NON-CUSTODIAL PARENT/ALLEGED FATHER

or

Select your race, the options are White, Black or African American,  American Indian or Native Alaskan, Federally Recognized Tribe,  Asain,  Native Hawaiian or Pacific Islander, and Two or more races. 

IF THE CHILD(REN) WERE BORN OUT OF STATE, ATTACH A COPY OF THE BIRTH CERTIFICATE, IF AVAILABLE.

IF THE PARENTS ARE/WERE MARRIED, PROVIDE DATE AND LOCATION

IF THE PARENTS ARE DIVORCED OR HAVE FILED FOR DIVORCE, PROVIDE DATE AND LOCATION

IF YES, COMPLETE COURT INFORMATION

COMPLETE THE FOLLOWING IF THE PARENTS WERE NOT MARRIED WHEN THE CHILD(REN) WERE BORN

IF YES, COMPLETE COURT INFORMATION

WHAT ARE THE NAMES AND ADDRESSES OF THE NONCUSTODIAL PARENT’S/ALLEGED FATHER’S PARENTS?

About our request for Social Security number (SSN) information: We need your SSN and that of your child(ren); the SSNs will be used to locate individuals for purposes of establishing paternity and establishing, modifying, and enforcing support obligations. Disclosure of these SSNs is mandatory per Section 466(a)(13) of the Social Security Act. We also ask that you provide the noncustodial parents or alleged father’s SSN if you know it. We need this information in order to identify the other parent in our records, to establish a support order, or to enforce a support order. Failure to provide this information may cause delays in delivering appropriate services to you.