ࡱ                >  	               t          v          s    	                  bjbjcTcT                  	 4r  > >                                                                               +      +      +      +      +                 ?      ?      ?      ?  4   s  D  ?             |   3      3      3      3             T     ,   d     f      f      f      f      f      f          [  d   f                     +      "                                  "      "      f              +      +      3              3     {                       "  
   +      3      +      3      d                                                                    "      d                                                                                                                3          "        ?      ,  .                 P       0                     Z  p                                                                                                     +        L   "      "            "      "                                      "      "      "      f      f                                        :                                   "      "      "            "      "      "      "                                                                                                "      "      "      "      "      "                                                              "      "      "        	    :     	                                                                                                                                                                                                                                                                                                                                                                                                                                      DEPARTMENT OF SOCIAL SERVICESDIVISION OF MEDICAL SERVICESTHIRD PARTY RESOURCE FORMPAY COTOACASE DCNELIGIBILITY SPECIALIST NUMBERDATE (MM/DD/YY)CHECK THE APPROPRIATE BOX FOR THE REQUESTED ACTION FORMCHECKBOX   ADD NEW RESOURCE     OR       FORMCHECKBOX   CHANGE RESOURCE FILESRECIPIENT NAMEMEDICAID ID NUMBER (DCN)*RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDERRECIPIENT NAMEMEDICAID ID NUMBER (DCN)RELATIONSHIP TO POLICYHOLDER* EXAMPLES OF RELATIONSHIP TO POLICYHOLDER:  SELF, SPOUSE, GRANDPARENT, GRANDCHILD, NEPHEW, NIECE, STEPCHILD, CHILD, COURT ORDERED CHILD, MOTHER, FATHER, SIGNIFICANT (SIG)  OTHERINSURANCE COMPANY NAMEEMPLOYER NAMEINSURANCE COMPANY ADDRESS (STREET)EMPLOYER ADDRESS (STREET)CITY, STATE, ZIP CODECITY, STATE, ZIP CODEPOLICYHOLDERS NAME (REQUIRED FIELD)POLICYHOLDERS DATE OF BIRTH (REQUIRED FIELD)POLICYHOLDERS SOCIAL SECURITY NUMBER (REQUIRED                                                 FIELD)POLICYHOLDERS ADDRESS (STREET)CITY, STATE, ZIP CODEPOLICY NUMBER (INCLUDE  ANY/ALL ALPHA PREFIX INFORMATION)  (REQUIRED FIELD)GROUP NUMBERELIGIBILITY SPECIALIST/SUPERVISOR SIGNATUREPHONE NUMBERMO 886-0458 (04/06)				DISTRIBUTION:  SEND ONE COPY TO TPL UNIT, STATE OFFICE			TPL-1 (04/06)				      	                            COPY FOR CASE RECORDADDITIONAL INFORMATIONTO BE COMPLETED BY THE THIRD PARTY LIABILITY UNITThis TPL-1 cannot be processed as requested.  Below is information regarding verification of this policy.  Please read and complete items as requested.  Return the TPL-1 and any attachments to the TPL Unit as soon as possible so the information can be verified and entered into the TPL database.  If you have any questions, please contact the TPL Unit at (573) 751-2005. FORMCHECKBOX Per verification with the insurance company, dependent(s)  FORMCHECKBOX   are   FORMCHECKBOX  are not covered on this policy.  If this is not correct, the client needs to contact the insurance company. FORMCHECKBOX Additional information is required in order to verify coverage.  Please attach copies of any documentation you have, i.e., insurance card, which could help identify the policy.  FORMCHECKBOX No action requested. FORMCHECKBOX Unable to read, please re-submit. FORMCHECKBOX Form not complete enough for verification by state.  Complete highlighted areas and re-submit. FORMCHECKBOX OtherMO 886-0458 (04/06)												TPL-1 (04/06)				                                                                                                                                                                                                                                                =  W  X  _  b  c  k                	  	  	  	  	  +	  S	  ٶ|kSB                   h-e! h= CJ OJ QJ ^J aJ  /j  h-e! hq CJ OJ QJ U^J aJ  h-e! hdV4 CJ OJ QJ ^J aJ  /j  h-e! hq CJ OJ QJ U^J aJ  h-e! hq CJ OJ QJ ^J aJ   h-e! hZX) CJ OJ QJ ^J aJ   h-e! h= CJ OJ QJ ^J aJ  #h-e! h= 5CJ OJ QJ ^J aJ  h-e! h= CJ OJ QJ ^J aJ  )j    h-e! h= CJ OJ QJ U^J aJ          =  W  X  _  c  l                                                          t                                                                                                                        {  kd  $$If   l             0 \(    $  
t  0                                6        4   4 
l a  yt-e!    $If   l                        *	  K            ;            ;            ;                                                             $If   l                 kd  $$If   l             r 4 \( (               8               
               	               (              
t  0                                6                                                              4   4 
l a  yt-e!  *	  +	  :	  S	  q	  r	  s	                                                                                                                                                                                                                                                 $If   l               h  kdw  $$If   l              \( (                
t  0                                6              4   4 
l a  yt-e!  S	  T	  `	  p	  s	  t	  	  	  	  	  	  	   
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       #  $  X  h  k  l                  0  @  C  D  x                            ޼ޫͫͫͫͫͫͫͫͫͫͫͫ     h-e! h{ CJ OJ QJ ^J aJ   h-e! h{ CJ OJ QJ ^J aJ   h-e! h= CJ OJ QJ ^J aJ   h-e! hZX) CJ OJ QJ ^J aJ   h-e! h= CJ OJ QJ ^J aJ   h-e! hdV4 CJ OJ QJ ^J aJ <s	  t	  	  	  	  	  	  q            a            a            a            a            a                                                                                                       $If   l                 kd  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
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t  0                                6                                      4   4 
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t  0                                6                                      4   4 
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t  0                                6                                      4   4 
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t  0                                6                                      4   4 
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  
  
    !  "  #  q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kdA  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!  #  $  3  L  i  j  k  q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kd  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!  k  l  {          q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kd  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!                q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kd<  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!        $  A  B  C  q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kd  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!  C  D  S  l        q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kd  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!                q            ^            ^            ^            ^            ^                                                                                                 $If   gdq l                 kd7  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!            q            ^            ^            ^                                                                                                                                   $If   gdq l                 kd  $$If   l             F , \(                                   <                
t  0                                6                                      4   4 
l a  yt-e!                   !  F  \  ^  b  s                    t  u  ͼͫͼuucRA       h-e! hpR CJ OJ QJ ^J aJ   h-e! h= CJ OJ QJ ^J aJ  #h-e! h= 5CJ OJ QJ ^J aJ #h-e! hez 5CJ OJ QJ ^J aJ #h-e! hpR 5CJ OJ QJ ^J aJ #h-e! h{ 5CJ OJ QJ ^J aJ  h-e! h{ CJ OJ QJ ^J aJ   h-e! h{ CJ OJ QJ ^J aJ   h-e! h{ CJ OJ QJ ^J aJ   h-e! hdV4 CJ OJ QJ ^J aJ   h-e! hZX) CJ OJ QJ ^J aJ                                                                                                                                                                                                                                                                 $If   l               h  kd  $$If   l              \( (                
t  0                                6              4   4 
l a  yt-e!                          t            t            t            t                                                                                                                                                              $If   l               {  kd   $$If   l             0 \(                                  
t  0                                6                          4   4 
l a  yt-e!                           t            t            t            t                                                                                                                                                              $If   l               {  kd   $$If   l             0 \(                                  
t  0                                6                          4   4 
l a  yt-e!     !  F  t                      t            t            t            t            t            t                                                                                                                            $If   l               {  kd,!  $$If   l             0 \(                                  
t  0                                6                          4   4 
l a  yt-e!              q            a            a            a            a                                                                                                                        $If   l                 kd!  $$If   l             F \(                  	                                 
t  0                                6                                      4   4 
l a  yt-e!      d  q  r  s  t              q            q            q            q            q                                                                                                                                       $If   gdq l               {  kdh"  $$If   l             0 \(                                  
t  0                                6                          4   4 
l a  yt-e!  t  u                      t            t            t            t                                                                                                                                                              $If   l               {  kd"  $$If   l             0 \(                                  
t  0                                6                          4   4 
l a  yt-e!  u      I  J  O  P      /  0  >  ?  @  {  |            ´£{f{Nf{f{6f{f    /jt&  h-e! hR-
 CJ OJ QJ U^J aJ /j &  h-e! hR-
 CJ OJ QJ U^J aJ )j    h-e! hR-
 CJ OJ QJ U^J aJ  h-e! hR-
 CJ OJ QJ ^J aJ  ,h-e! hR-
 5B*CJ OJ QJ ^J aJ ph   h-e! hR-
 CJ OJ QJ ^J aJ  hZX) CJ OJ QJ ^J aJ  hdV4 CJ OJ QJ ^J aJ  hpR CJ OJ QJ ^J aJ   h-e! hpR CJ OJ QJ ^J aJ   h-e! hpR CJ OJ QJ ^J aJ     J  K  L  M  N  O  P  g  h  i  j                                                                                                  h            h            h            h               $ &`#$/ If   gd-e! l                  {  kd#  $$If   l             0 \(                                  
t  0                                6                          4   4 
l a  yt-e!  j  k  l  m  n  o  p  q  r  s  t  u  v  w  x  y  z  {  |  }  ~                                                                                                                                                                                                                                                                                                                                                     $ &`#$/ If   gd-e! l                                                                u                                                                                                                                                                          o  kd!$  $$If   l              \( (              
t  6`  0                                6               4   4 
l a  yt-e!    $ &`#$/ If   gd-e! l                    .              f                                                                                                                                                                                     $ &`#$/ If   gd-e! l                 kd$  $$If   l              \( (                	  
t  6`  
         0                                6               4   4 
l a  p
         yt-e!  .  /  A                u            u                                                                                                                                                                                                  $ &`#$/ If   gd-e! l                o  kdf%  $$If   l              \( (            
t  6`  0                                6            4   4 
l a  yt-e!              $  %  &              	        @  A  O  P  Q            zbJ    /j1  h-e! hR-
 CJ OJ QJ U^J aJ /j/  h-e! hR-
 CJ OJ QJ U^J aJ /j`-  h-e! hR-
 CJ OJ QJ U^J aJ /j8+  h-e! hR-
 CJ OJ QJ U^J aJ /j)  h-e! hR-
 CJ OJ QJ U^J aJ )j    h-e! hR-
 CJ OJ QJ U^J aJ /j&  h-e! hR-
 CJ OJ QJ U^J aJ  h-e! hR-
 CJ OJ QJ ^J aJ         |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd\'  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!      '    |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd6(  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!          |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd)  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!          |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd^*  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!          |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd+  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!        <  |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd,  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!  <  =  >  ?  |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd-  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!  ?  @  R    |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd.  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!          |            b            b                                                                                                                                                            $ &`#$/ If   gd-e! l                  kd/  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!                          |            b            b            b            b            b            b            b            b            b            b                    $ &`#$/ If   gd-e! l                  kd0  $$If   l             0 h\(    &  
t  6`  0                                6         4   4 
l a  yt-e!                                                                                                                                                                                                                                                                                                                                                                                                                                         $ &`#$/ If   gd-e! l                          |            z            z            z                                                                                                                                                                                              kd&2  $$If   l             0 h\(      &    
t  6`  0                                6               4   4 
l a  yt-e!                Ŵ                                                                                                                                                                                                                                                                                                                                       hpR h2_ CJ OJ QJ ^J aJ  hpR CJ OJ QJ ^J aJ  hdV4 CJ OJ QJ ^J aJ  hR-
 CJ OJ QJ ^J aJ   h-e! hR-
 CJ OJ QJ ^J aJ 2 1h:p= / =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                D d   
             ,                                  <   
      
  C    A                   b m  4ɻ|{+n(3
 I     D       nA  4ɻ|{+n(3
PNG

   IHDR       !   gAMA     PLTE   ٟ   	pHYs    +  IDATxo$Gvǫ,@d.tpYPp߿.09h;p@mc'jn3kx[{=ᮭ4dUޯzjDk̛`{07<gg3fcI\n?(lQ{v>\nkfT<pO3evnm:sbz[!1_h7۶<Ic4m(7qG0݌Sw2Vy㶘 !.~gSkHd»UpNRýqL0|z[Fz1ª(w1ND!0WsT@=ӾyPLS1N=%0msC8pJk?cio@]T2IC%1Jo-i_0td=8<f%3^wƛR;6p2]"`c8ҀbV5"V?*cŐ
pJKY;}=iNTx-314lұQw-cvz'|ibSeOk~XfKcnȧd|1s/yrR'1)MۚTX$;UPֽq2iD~͈Cem.-s#GygzB>txCuh)E><@9t- xҧʣیއ	M탥p0c
ud!&go3ͮȑu}Vaz#bA.rL?WNz])5p
tbXyNǼjAYVwҳ ZgLo&gyq=f^Nc+򺆥8ZKEcz>6J̢jse8abkL̄:$曓a[ Z9QA1adwXE5-X @2^:"'T61Xw4&`1Hʍ $})Eǔ2x1'XELJ	)%bs/E1JnDA܍S\OsC2<ygD&m\K35=14k-`El]v7/lߗFpfOubXRKK.^<gQsB	$3h(эF1wLK\A:!\³ʐasGol$EMމDO!?<5+Gh-ʛ!2Ed}l"E	dr51l9Gc('w'{MR7pw'
Ju{/v|W"@Q{6eVZ&OC3Rj+m`L$ M
v(h"CbI9&CZ	
W*LCv0TuOM.{I;LG1&q\ceq,9HwED1c0A"% 7=gaekng39ٶ`LebD
L9a-#-pyXµ38W7di\ Yߠh/<&)jⱗ032oXf0+kyCŽOdڰM3h' M9^3k;І5YhmbLpP]X]Ez8hyN-u/xiOiz'/>{|0/sb5eɡمx$̤HL9**%ˁSi9wLHT ,Exa;dn2YϬ0yR"%'_F#쬩-p	`)rytD3ꖥ0r$<G7qVĨ91_ЗzјlBe:ucK[?$3M2	N꠪F0c+A9	;:ERMaW=8gW}I9٘fᯙF/|D잡?"&쾠gW04O|D:\r"wf\&f\.cjْ_ qSȕ__4{&g&yu.lmAc'H$e5Wq}"J=&ӿ%?V1;.0NɭH82{|Fnv3lG"LU6Uˇ`޹{ϒ|uOhDqk
1^Z[N!HF<]!Xz*т

Aš/bt?1&eDwg{lyzb({unD6>૴LevbL?Yz=Т{>4<ΠKT7kFupl}?T81Q1ļcٮmj$މRÚׯv!2;Nide^Ӡm@ACEBW "Cl.m2jl}UFR*K}1ΎʣUb?<$Y8P`WGKlz)׫Ӂ>k`قRl:W#-M6uF
rS!jdKAUǜjXP.}QPc{fP0ؑ}#-@)0KjbW7@wU83`'/8?H(G{>^쎫+ʒȨY8BTQ7d矄>J#?mh^!-ћmǠ
3m0+n{\3kYSc-P0@L-R#	Q(fD<f>D'\M'硐3j8^)1[֥WzQ52.Tbo׏QHa\l3$OTr}mI={U.JCKqDeA"uшuܠlԜmM9`3b^˼l>m;c&XfO,}pχ8կc_Qδ)B|W+Pq#3ԓp3l/>;811ž`R㓜<zT;:dULLPn('&0X IA%h{pP	,7fA}~FQIKux(yKͲyQH_@mxEyy\z1|]e1TȮ'sPsܝ"J0K,~U/RMpY]CF+Oj1#_Ԙk:ZoC*L>B/L|n౅E5d٣K͙;8}:ݠcu'ݖiH+GǇqNV7-sml8:e\1ŎE{=Is5tHgCT)We-*1(g_1FY/ݺJE6{:R)Nԓ3/e{~(q;PHq >gQM9^XوtLCiA2.yq ,p^dsˉSr@fjub,y]d
|>_SMC,tj'}8"C=F粑JLؕA˦-IUN/Ao3Z(rY?jM8|{@6*>4Pu.`,SL!>9+v2_5`QPuU^!;դyWcsvTyH>?\+l}(VVcxq3e6ʉ2hv{[+0ҝcOě[Y8sKwZ_RD6&&
Kg$jMƉlS:h<zZҩ@{m)&쪘ЗntwťS[XNG#Zk>Ippl6ge\eIᣁz%&Q<8|LBjb>wG%$Uӑu{L\ ^a)c3L墙m4QUTĸYe\3j:o3kViT7Hc.[1ct{!viqY^qFvhdAvK <ǡvB8J)CCUmN0W.ݝ6Tlv7lΨ	~u-C'=Te'ҎAЖtx),nw[Ci7qmwrwߍ70Aě+qf\Q[	}6gfSKg0^tFϥSy`TϻWQkbz&&CwC.g@P\*lJ?ץÎHT2dQ_<teKz{s|aUBoܖo}c<mAFnf$bJٺ&?&[x-y2w>>P3-k[?+0]#M=G͟N'ogHgơQxz;B=f&w׵bfi{ЬPVh1]m>&wqn>{u֣gN:/gw|_K[an&}g w;|    IENDB` $$If     !v h5 5$#v #v$:V l 
t  0                                65 5$/ /      yt-e!  $$If     !v h5 (585
5	5(#v (#v8#v
#v	#v(:V l 
t  0                                65 (585
5	5(/      yt-e! t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         { $$If     !v h5 (#v (:V l 
t  0                                65 (yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e!  $$If     !v h5 55<#v #v#v<:V l 
t  0                                65 55<yt-e! { $$If     !v h5 (#v (:V l 
t  0                                65 (yt-e!  $$If     !v h5 5#v #v:V l 
t  0                                65 5yt-e!  $$If     !v h5 5#v #v:V l 
t  0                                65 5yt-e!  $$If     !v h5 5#v #v:V l 
t  0                                65 5yt-e!  $$If     !v h5 5	5#v #v	#v:V l 
t  0                                65 5	5yt-e!  $$If     !v h5 5#v #v:V l 
t  0                                65 5yt-e!  $$If     !v h5 5#v #v:V l 
t  0                                65 5yt-e!  $$If     !v h5 5#v #v:V l 
t  0                                65 5yt-e!  $$If     !v h5 (#v (:V l 
t  6`  0                                6 5 (/      yt-e!  $$If     !v h5 (#v (:V l 	  
t  6`  
         0                                6 5 (p
         yt-e!  $$If     !v h5 (#v (:V l 
t  6`  0                                6 5 (/ yt-e! t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         t   D                                                               e     C h e c k 5                          $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e!  $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e! t   D                                                               e     C h e c k 6                          $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e!  $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e! t   D                                                               e     C h e c k 7                          $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e!  $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e! t   D                                                               e     C h e c k 8                          $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e!  $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e! t   D                                                               e     C h e c k 9                          $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e!  $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ /      //     yt-e! v   D                                                               e     C h e c k 1 0                          $$If     !v h5 5&#v #v&:V l 
t  6`  0                                6 5 5&/ 	/      //     yt-e!                                                                                                                                                                                                                                                                 ^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2                     0  @  P  `  p                   2  (         0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p      8  X        V  ~     _HmH	nH	sH	tH	    @  ` @          N o r m a l       CJ _HaJ mH	sH	tH	                  D A  D          D e f a u l t   P a r a g r a p h   F o n t     R i@ R          T a b l e   N o r m a l      4 
l 4   a      ( k  (           N o   L i s t         j @  j   =   
 T a b l e   G r i d   7 :V 0                                   PK     !         [Content_Types].xmlj0Eжr(΢Iw},-j4	wP-t#bΙ{UTU^hd}㨫)*1P'	^W0)T9<l#$yi};~@(Hu*Dנz/0ǰ$X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?   PK     ! ֧   6     _rels/.relsj0}Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/Seе   PK     ! ky         theme/theme/themeManager.xmlM
 @}w7c(Ebˮ CAǠҟ7՛KY,e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8   PK     !   P     theme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$!)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu	gZo~ٺlAplxpT0+[}`jzA V2Fi@qv֬5\|ʜ̭NleXdsjcs7fW+Ն7`gȘJj|h(KD- dXiJ؇(x$(:;˹!I_TS1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ
x}rxwr:\TZaG*y8IjbRc|XŻǿI
u3KGnD1NIBs
RuK>V.EL+M2#'fi~Vvl{u8zH
*:(W☕~JTe\O*tHGHY }KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4=3ڗP
1Pm\\9Mؓ2aD];Yt\[x]}Wr|]g-
eW)6-rCSjid	DЇAΜIqbJ#x꺃6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8քAV^fHn-"d>znǊ	ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ ;%1U٥m;R>QDDcpU'&LE/pm%]8firS4d7y\`JnίIR3U~7+׸#mqBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D	vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCMm<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍ    PK     ! ѐ     '   theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э56?$Q,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/]QAsم(#L[    PK-      !                       [Content_Types].xmlPK-      ! ֧   6               +  _rels/.relsPK-      ! ky                     theme/theme/themeManager.xmlPK-      !   P                 theme/theme/theme1.xmlPK-      ! ѐ     '             	  theme/theme/_rels/themeManager.xml.relsPK      ]  
    <?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>        r       S	    u                 %   +   8        *	  s	  	  
  K
  
  
  #  k      C                   t    j      .              <  ?                                                                      !   "   #   $   &   '   (   )   *   ,   -   .   /   0   1   2   3   4   5   6   7             /
  ?
  {
  
  
  
    %          @  P        G$G$G$G$G$G$G$G$G$G$  8                         @                           0    (    	                    
          B    
        S              	   ?          
    C h e c k 1  C h e c k 2  C h e c k 3  C h e c k 4  C h e c k 5  C h e c k 6  C h e c k 7  C h e c k 8  C h e c k 9  C h e c k 1 0      0
  |
  
      	  A                                  	        @
  
  
  &      Q                 	  $	      R       3  3  3                  _  _  P  P                                        P  P                                            > R-
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   @     L     X     d     p     x                                           kappcwd                           Normal.dotm       Stephanie L. Roettgen         2         Microsoft Office 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Department of Social Services                                                              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                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   U   V   W   X   Y   Z   [   \   ]   ^   _   `   a   b   d   e   f   g   h   i   j   l   m   n   o   p   q   r   u   R o o t   E n t r y                                                 	           F            p-,w          D a t a                                                         
                                     :    3      1 T a b l e                                                                                                T         W o r d D o c u m e n t                                                                                        4r       S u m m a r y I n f o r m a t i o n                           (                                     c           D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        k           C o m p O b j                                                                                           y                                                                                                                               
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