ࡱ                >  	               Z          \          Y   t    #`	                  bjbjmm                  	 8                                                                           Z      Z  Z      Z      Z      Z      Z             n      V       V       V   8        !     n      4     Z"    &  (   $'      $'      $'      '  
  	*  ,  5+     3     3      3      3      3      3      3      5  h  8  \   3                     Z      +                      '      '      +      +      3              Z      Z      $'              $'     4     M1      M1      M1      +  |   Z      $'      Z      $'      3              M1                                                      +      3              M1              M1      Z      Z                                                              M1      $'      N"      ӹ/2h        V       I,  |   M1              12    4  0   4      M1      z8      ,  ~  z8      M1                                                                              z8              Z      M1     +      +      M1      +      +                                      +      +      +      3      3                                      C1  
                                   +      +      +      4      +      +      +      +              n      n      n  $      n      n      n            n      n      n      Z      Z      Z      Z      Z      Z      4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            E M B E D   P r e s e n t a t i o n s . D r a w i n g . 1 0         M i s s o u r i   D e p a r t m e n t   o f   S o c i a l   S e r v i c e s ,   F a m i l y   S u p p o r t   D i v i s i o n    O l d e r   B l i n d   G r a n t   D a t a   S h e e t      O B S   1   N a m e   ( L a s t ,   F i r s t ,   M I )     F O R M T E X T            C a s e   N u m b e r     F O R M T E X T             A d d r e s s   ( S t r e e t   o r   R R )     F O R M T E X T             C i t y     F O R M T E X T            S t a t e     F O R M T E X T            Z i p     F O R M T E X T            C o u n t y   &   N o .     F O R M T E X T             T e l e p h o n e     F O R M T E X T            S o c i a l   S e c u r i t y   #     F O R M T E X T            D a t e   o f   B i r t h   ( M M / D D / Y Y )     F O R M T E X T             R e f e r r a l   D a t e     F O R M T E X T            A p p l i c a t i o n   D a t e     F O R M T E X T            C a s e l o a d   #     F O R M T E X T             P r e v i o u s   O B S   C a s e     F O R M T E X T            I f   Y e s ,   D a t e   o f   C l o s u r e     F O R M T E X T             D a t e   o f   E l i g i b i l i t y     F O R M T E X T            G e n d e r     F O R M C H E C K B O X       1 )   M a l e              F O R M C H E C K B O X       2 )   FemaleRace/Ethnicity FORMCHECKBOX 1) White (Non-Hispanic) FORMCHECKBOX 2) African-American (Non-Hispanic) FORMCHECKBOX 3) American Indian or Alaskan Native FORMCHECKBOX 4) Asian FORMCHECKBOX 5) Hawaiian Native or Other Pacific Islander FORMCHECKBOX 6) Hispanic or Latino FORMCHECKBOX 7) Other (Specify)  FORMTEXT                                                                                                                                                                               V i s u a l   D i s a b i l i t y   ( C h e c k   O n l y   O n e   V i s u a l   D i s a b i l i t y )     F O R M C H E C K B O X     1 )   T o t a l l y   B l i n d   ( L P   O n l y   o r   N L P )     F O R M C H E C K B O X     2 )   L e g a l l y   B l i n d   ( E x c l u d i n g   T o t a l   B l i n d n e s s )  R e p o r t e d / S n e l l e n   A c u i t y :        F O R M T E X T               F O R M C H E C K B O X     3 )   P r o g r e s s i v e   C o n d i t i o n   2 0 / 7 0   o r   W o r s e   C o r r e c t e d   B i l a t e r a l   A c u i t y  R e p o r t e d / S n e l l e n   A c u i t y :        F O R M T E X T             M a j o r   C a u s e   o f   V i s u a l   I m p a i r m e n t s   ( A s   R e p o r t e d   b y   t h e   I n d i v i d u a l )     F O R M C H E C K B O X     1 )   M a c u l a r   D e g e n e r a t i o n     F O R M C H E C K B O X     2 )   D i a b e t i c   R e t i n o p a t h y     F O R M C H E C K B O X 3) Glaucoma FORMCHECKBOX 4) Cataracts FORMCHECKBOX 5) OtherNon-Visual Impairments/Conditions At Time of Intake As Reported by the Individual. Please Check One of the Following If Applicable. FORMCHECKBOX 1) Hearing Impairment FORMCHECKBOX 2) Mental Impairments  Includes Cognitive Impairments (Impairments Involving Learning, Thinking, Processing Information and Concentration); Psychosocial Impairments (Inter-Personal and Behavioral Impairments, Difficulty Coping; Alzheimer's; and Other Mental Impairments) FORMCHECKBOX 3) Cancer FORMCHECKBOX 4) Cardiac and Other Conditions of the Circulatory System FORMCHECKBOX 5) Diabetes Mellitus FORMCHECKBOX 6) End Stage Renal Disease and Genitou-Urinary System FORMCHECKBOX 7) Musculoskeletal (Arthritis, Rheumatism, Amputations, Fractures/Injuries Which Resulted In Permanent Loss/Impairment of Limb Function) FORMCHECKBOX 8) Neurological Impairments/Disorders Due To: Stroke (CVA) With Resulting Paralysis or Weakness, Peripheral or Diabetic Neuropathy, Other Conditions Affecting the Central Nervous System (Including Parkinson's Disease, Seizure Disorders, Cerebral Palsy, Multiple Sclerosis, Etc.) FORMCHECKBOX 9) Respiratory or Lung Conditions FORMCHECKBOX 10) OtherOnset of Significant Vision Loss (When Loss Began To Affect Performance of Daily Activities) FORMCHECKBOX 1) Less Than 1 Year Before Il Services FORMCHECKBOX 2) 1-3 Years FORMCHECKBOX 3) 4-6 Years FORMCHECKBOX 4) 7-9 Years FORMCHECKBOX 5) 10 Years or MoreHighest Level of Education Completed FORMCHECKBOX 1) No Formal Schooling FORMCHECKBOX 2) Elementary Education (Grades 1-8) FORMCHECKBOX 3) Secondary Education, No High School Diploma (Grades 9-12) FORMCHECKBOX 4) High School or Equivalency Certificate FORMCHECKBOX 5) Post Secondary Education (Less Than Bachelor's Degree) FORMCHECKBOX 6) Bachelor's Degree or Higher FORMCHECKBOX 7) Master's Degree or HigherType of Living Arrangement At Time of Intake FORMCHECKBOX 1) Live Alone FORMCHECKBOX 2) Live With Spouse FORMCHECKBOX 3) Live With Personal Care Assistant FORMCHECKBOX 4) Live With OtherSetting of Residence At Time of Intake FORMCHECKBOX 1) Private Residence  Apartment or Home Alone, or With Roommate, Personal Care Assistant, Family or Other Person FORMCHECKBOX 2) Community Residential FORMCHECKBOX 3) Assisted Living Center FORMCHECKBOX 4) Nursing Home or Long Term Care Facility FORMCHECKBOX 5) Other (Please Specify)   FO R M T E X T             S o u r c e   o f   R e f e r r a l     F O R M C H E C K B O X     1 )   E y e   C a r e   P r o v i d e r   ( O p h t h a l m o l o g i s t ,   O p t o m e t r i s t )     F O R M C H E C K B O X     2 )   G e n e r a l   P r a c t i t i o n e r ,   P r i m a r y   C a r e   P r o v i d e r ,   o r   O t h e r   M e d i c a l   P e r s o n n e l   o r   M e d i c a l   I n s t i t u t i o n     F O R M C H E C K B O X     3 )   S t a t e   V R   A g e n c y  Counselor or Other Agency Staff FORMCHECKBOX 4) Social Service Agency FORMCHECKBOX 5) Self-Referral FORMCHECKBOX 6) Family Member or Friend FORMCHECKBOX 7) Veterans Administration FORMCHECKBOX 8) Senior Program FORMCHECKBOX 9) Religious Organization FORMCHECKBOX 10) Community Rehabilitation Program FORMCHECKBOX 11) Other Sources (e.g. Public Service Announcement)Do You Feel, After Discussion of the Services Offered by Rehabilitation Services for the Blind, That Your Health Will Allow You To Be More Independent? FORMCHECKBOX   Yes            FORMCHECKBOX   NoServices administered by Rehabilitation Services for the Blind, Missouri Family Support Division are in compliance with the Civil Rights Act of 1964 and/or section 504 of the Rehabilitation Act of 1973, as amended. An application presumed eligible for Older Blind Services from the State when evidence exists which establishes that the applicant has a significant disability and meets the eligibility criteria for Older Blind Services. Discrimination against any person on the basis of race, national origin, religion, political preferences, or disabling condition is prohibited. All information given by me to a representative of Rehabilitation Services for the Blind is confidential and may be used only for the purpose of carrying out my rehabilitation program, except situations where Federal or State laws take precedence over the Rehabilitation Act of 1973.                                                               D  F  H  J  L  t  x          	  	  	  "	  F	  H	  Ǵݥ}m^N?^                                h\_ hGcb CJ$ OJ QJ aJ$  h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ h|a/ CJ$ OJ QJ aJ$  hY h|a/ 5CJ  OJ QJ aJ  hY hGcb 5CJ OJ QJ aJ htV CJ OJ QJ aJ  hY CJ OJ QJ aJ  hY hGcb CJ OJ QJ aJ  %j    hY htV CJ  OJ QJ UaJ  +jE
hY h|a/ CJ  OJ QJ UVaJ  hY h|a/ CJ  OJ QJ aJ   %j    hY h|a/ CJ  OJ QJ UaJ      L    	  	  H	  p	  	  	                                      l            c            c            c            c                                                                      	  $If   gdY ~  kd  $$If                g0 8m+U                 5'                
t  0                              +                            4   4 
 a  yttV 	  $If   gdtV   $$If   a$gdtV     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 H	  J	  ^	  `	  b	  l	  n	  p	  	  	  	  	  	  	  	  	  	  	  	  	  쟏iZK<                     h\_ hGcb CJ$ OJ QJ aJ$  h\_ h|a/ CJ$ OJ QJ aJ$  h\_ hl CJ$ OJ QJ aJ$  +je  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h|a/ 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ hTe CJ$ OJ QJ aJ$  0j    h\_ hM)6 CJ$ OJ QJ UaJ$ mH nH u +jC  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  %j    h\_ hM)6 CJ$ OJ QJ UaJ$  	  	  	  
              x            x                                                                                                                                                                                                     	  $If   gdY ~  kd  $$If                Q0 m+                                  
t  0                              +                            4   4 
 a  yttV  	  	  	  	  	  	  	  	  
  
  
  

  
  
  
  *
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  .
  8
  :
  ôÅvfVô@Å                             +j  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h|a/ 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ hq+, CJ$ OJ QJ aJ$  0j    h\_ hM)6 CJ$ OJ QJ UaJ$ mH nH u +j  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  %j    h\_ hM)6 CJ$ OJ QJ UaJ$ h\_ h|a/ CJ$ OJ QJ aJ$  h\_ hGcb CJ$ OJ QJ aJ$  hY CJ$ OJ QJ aJ$ 
  

  
  <
  H
  p
  x
  
  
  
                                                                                                                                                                                                                                       	  $If   gdY k  kd,  $$If                 m+ +                
t  0                              +                4   4 
 a  yttV  	:
  <
  F
  H
  J
  ^
  `
  b
  l
  n
  p
  v
  x
  z
  
  
  
  
  
  
  
  
  
  
  ѾqѾ[LѾ                                 h\_ hl CJ$ OJ QJ aJ$  +j  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h|a/ CJ$ OJ QJ aJ$  0j    h\_ hM)6 CJ$ OJ QJ UaJ$ mH nH u +j	  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  %j    h\_ hM)6 CJ$ OJ QJ UaJ$ h\_ h|a/ 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ hTe CJ$ OJ QJ aJ$ 
  
  
  
  
  
  
  
  
  
               B  D  F  Z  \  ֽ֮pZֽKp5  +jf  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hTe CJ$ OJ QJ aJ$  +j  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  h\_ h|a/ 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ h|a/ CJ$ OJ QJ aJ$  h\_ hl CJ$ OJ QJ aJ$  0j    h\_ hM)6 CJ$ OJ QJ UaJ$ mH nH u %j    h\_ hM)6 CJ$ OJ QJ UaJ$ +j%  h\_ hk9O CJ$ OJ QJ UaJ$  
  
  
     D  l      ]            T            T            T            T            T            T                                                         	  $If   gdY   kd  $$If                \ m+                  8                                                  
t  0                              +                                                    4   4 
 a  yttV  \  ^  h  j  l  v  z                            ĴzkUFz                                         h\_ hl CJ$ OJ QJ aJ$  +j2  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  h\_ h|a/ CJ$ OJ QJ aJ$  hY hGcb CJ  OJ QJ aJ   h\_ hGcb CJ$ OJ QJ aJ$  hY 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ hq+, CJ$ OJ QJ aJ$  0j    h\_ hM)6 CJ$ OJ QJ UaJ$ mH nH u %j    h\_ hM)6 CJ$ OJ QJ UaJ$          .  V  l    p            g            g            g            g            g            g                                                                                               	  $If   gdY   kd  $$If                F m+                                                   
t  0                              +                                        4   4 
 a  ytb              
  .  0  D  F  H  R  T  l  n              ۑ~oY~@~o                   0j    h\_ hGcb CJ$ OJ QJ UaJ$ mH nH u +j  h\_ hGcb CJ$ OJ QJ UaJ$ h\_ hGcb CJ$ OJ QJ aJ$  %j    h\_ hGcb CJ$ OJ QJ UaJ$ .j  h\_ hGcb 5CJ$ OJ QJ UaJ$  3j    h\_ hGcb 5CJ$ OJ QJ UaJ$ mH nH u.j]  h\_ hGcb 5CJ$ OJ QJ UaJ$  h\_ hGcb 5CJ$ OJ QJ aJ$ (j    h\_ hGcb 5CJ$ OJ QJ UaJ$           :  p            g            g            g            g                                                                                                                                 	  $If   gdiPj   kdq  $$If                F - m+ %                 %                 @                
t  0                              +                                        4   4 
 a  ytb                             (  *  ,  6  8  <  F  ڨzdzKz;                   h\_ hGcb 5CJ$ OJ QJ aJ$ 0j    h\_ hiPj CJ$ OJ QJ UaJ$ mH nH u +j   h\_ hiPj CJ$ OJ QJ UaJ$ %j    h\_ hiPj CJ$ OJ QJ UaJ$ hiPj CJ$ OJ QJ aJ$  h\_ hiPj CJ$ OJ QJ aJ$  3j    h\_ hiPj 5CJ$ OJ QJ UaJ$ mH nH u.j  h\_ hiPj 5CJ$ OJ QJ UaJ$  (j    h\_ hiPj 5CJ$ OJ QJ UaJ$  h\_ hiPj 5CJ$ OJ QJ aJ$  :  <  d                    z            z            z            z                                                                                                                                                                       	  $If   gdY |  kd!  $$If                0 m+                                  
t  0                              +                            4   4 
 a  ytiPj  F  J  b  d  f  z  |  ~                      ҽ{hYCh4               h\_ h\_ CJ$ OJ QJ aJ$  +j	#  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  %j    h\_ hM)6 CJ$ OJ QJ UaJ$ 3j    h\_ hM)6 5CJ$ OJ QJ UaJ$ mH nH u.jG"  h\_ hk9O 5CJ$ OJ QJ UaJ$  h\_ hM)6 5CJ$ OJ QJ aJ$ (j    h\_ hM)6 5CJ$ OJ QJ UaJ$  h\_ hTe 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ hY 5CJ$ OJ QJ aJ$                          &  '  (  +  ?  @  Ϲު{fV>f/     hiPj hGcb CJ$ OJ QJ aJ$  .j$  h\_ hk9O 5CJ$ OJ QJ UaJ$  h\_ h^' 5CJ$ OJ QJ aJ$ (j    h\_ h^' 5CJ$ OJ QJ UaJ$  h\_ hTe 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ h\_ hTe CJ$ OJ QJ aJ$  h\_ h\_ CJ$ OJ QJ aJ$  +j#  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hM)6 CJ$ OJ QJ aJ$  %j    h\_ hM)6 CJ$ OJ QJ UaJ$ h\_ hGcb CJ$ OJ QJ aJ$       @  t        )                z            z            z            z            z            z            z            z                                                                                                   	  $If   gdY |  kd5$  $$If                0 m+                                  
t  0                              +                            4   4 
 a  ytiPj  	@  A  O  P  Q  s  t  u                                                츩ݓ츇q츩[츇                            +j'  h\_ hk9O CJ$ OJ QJ UaJ$ +j>'  h\_ hk9O CJ$ OJ QJ UaJ$ hY CJ$ OJ QJ aJ$  +jF&  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hTe CJ$ OJ QJ aJ$  h\_ hGcb CJ$ OJ QJ aJ$  +j`%  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h^' CJ$ OJ QJ aJ$  %j    h\_ h^' CJ$ OJ QJ UaJ$          !  (  )  *  8  9  :  M  N  X  Y     
      ǻǬ֝rbJr0r  3j    h\_ h^' >*CJ$ OJ QJ UaJ$ mH nH u.j*  h\_ hk9O >*CJ$ OJ QJ UaJ$  h\_ h^' >*CJ$ OJ QJ aJ$ (j    h\_ h^' >*CJ$ OJ QJ UaJ$  +j)  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h^' CJ$ OJ QJ aJ$  h\_ hTe CJ$ OJ QJ aJ$  hY CJ$ OJ QJ aJ$  h\_ hGcb CJ$ OJ QJ aJ$  %j    h\_ h^' CJ$ OJ QJ UaJ$ +j(  h\_ hk9O CJ$ OJ QJ UaJ$      z    \    `                                                                                                                                                                                                                               $If   ^gdiPj 	  $If   gdY i  kd+  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb    2  x  z  |                            ҿ|p|aN?                                     h\_ h<o CJ$ OJ QJ aJ$  %j    h\_ h<o CJ$ OJ QJ UaJ$ h\_ hTe CJ$ OJ QJ aJ$  hY CJ$ OJ QJ aJ$  h\_ h. CJ$ OJ QJ aJ$  h\_ hGcb CJ$ OJ QJ aJ$  +j+  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h^' CJ$ OJ QJ aJ$  %j    h\_ h^' CJ$ OJ QJ UaJ$ h\_ hTe 5CJ$ OJ QJ aJ$ htV 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$         Z  \                            Ǹǣ{aR<                               +j/  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h<o CJ$ OJ QJ aJ$  3j    h\_ h<o >*CJ$ OJ QJ UaJ$ mH nH u.jy.  h\_ hk9O >*CJ$ OJ QJ UaJ$  h\_ h<o >*CJ$ OJ QJ aJ$ (j    h\_ h<o >*CJ$ OJ QJ UaJ$  h\_ hTe CJ$ OJ QJ aJ$  h\_ hGcb CJ$ OJ QJ aJ$  %j    h\_ h<o CJ$ OJ QJ UaJ$ +jg-  h\_ hk9O CJ$ OJ QJ UaJ$        ^  `                             iYLY;- hY @CJ$ OJ QJ aJ$   h\_ hGcb @CJ$ OJ QJ aJ$  hY 5CJ$ OJ QJ aJ$ h\_ hGcb 5CJ$ OJ QJ aJ$ 3j    h\_ h<o >*CJ$ OJ QJ UaJ$ mH nH u.j51  h\_ hk9O >*CJ$ OJ QJ UaJ$  h\_ h<o >*CJ$ OJ QJ aJ$ (j    h\_ h<o >*CJ$ OJ QJ UaJ$  h\_ hGcb CJ$ OJ QJ aJ$  h\_ hTe CJ$ OJ QJ aJ$   h\_ h0 @CJ$ OJ QJ aJ$   h\_ hGcb @CJ$ OJ QJ aJ$     B        .  H                                                                                                                                                                                                                                                     	  $If   gdY i  kd2  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb     "  (  @  B  D  `  b  d                                     !  -  .  ҿҿuҿ_ҿI  +j6  h\_ hk9O CJ$ OJ QJ UaJ$ +j|5  h\_ hk9O CJ$ OJ QJ UaJ$ +j4  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ hGcb CJ$ OJ QJ aJ$  +j2  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h<o CJ$ OJ QJ aJ$  %j    h\_ h<o CJ$ OJ QJ UaJ$ h\_ hTe CJ$ OJ QJ aJ$  hY @CJ$ OJ QJ aJ$   h\_ hGcb @CJ$ OJ QJ aJ$ .  /  =  >  ?  G  I  s  u  }  ~                            츩n]n]nLn]n]nLn                                  h h @CJ  OJ QJ aJ    h hY @CJ  OJ QJ aJ    h h0 @CJ  OJ QJ aJ   htV 5CJ$ OJ QJ aJ$ hY 5CJ$ OJ QJ aJ$ h\_ h0 5CJ$ OJ QJ aJ$ h\_ hTe CJ$ OJ QJ aJ$  h\_ hGcb CJ$ OJ QJ aJ$  +j6  h\_ hk9O CJ$ OJ QJ UaJ$ h\_ h<o CJ$ OJ QJ aJ$  %j    h\_ h<o CJ$ OJ QJ UaJ$  H  I  ~        4                                                                |                                                            |            |                                                             `$If   ^``gdfld 	  $If   gdY i  kd7  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb                        D  E                                (  )  *  4  5  ݱݢxxiS  +j;=  h\_ h0 CJ$ OJ QJ UaJ$ hE}L h CJ  OJ QJ aJ   hE}L CJ  OJ QJ aJ   hE}L hY CJ  OJ QJ aJ   hE}L h CJ  OJ QJ aJ   hE}L h0 CJ  OJ QJ aJ   +j:  h\_ h0 CJ$ OJ QJ UaJ$ +j+8  h\_ h0 CJ$ OJ QJ UaJ$ h\_ h0 CJ$ OJ QJ aJ$  %j    h\_ h0 CJ$ OJ QJ UaJ$   5  C  D  E  P  S  e  g  h  k                                      9  :  u  zk\k                              hE}L h CJ  OJ QJ aJ   hE}L h0 CJ  OJ QJ aJ   +jA  h\_ h0 CJ$ OJ QJ UaJ$ +j?  h\_ h0 CJ$ OJ QJ UaJ$ +j?  h\_ h0 CJ$ OJ QJ UaJ$ hY CJ$ OJ QJ aJ$  %j    h\_ h0 CJ$ OJ QJ UaJ$ +j=  h\_ h0 CJ$ OJ QJ UaJ$ h\_ h0 CJ$ OJ QJ aJ$ u  w                          7  :                                ӪyӏcS            h\_ h0 5CJ$ OJ QJ aJ$ +jF  h\_ h0 CJ$ OJ QJ UaJ$ +jF  h\_ h0 CJ$ OJ QJ UaJ$ hY CJ$ OJ QJ aJ$  h\_ hY CJ$ OJ QJ aJ$  +jC  h\_ h0 CJ$ OJ QJ UaJ$ %j    h\_ h0 CJ$ OJ QJ UaJ$ h\_ h0 CJ$ OJ QJ aJ$  hE}L h0 CJ  OJ QJ aJ   hE}L hY CJ  OJ QJ aJ      [                                                                                                                                                                                                                                                               	  $If   gdY i  kdCH  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb        F  H  [  \  j  k  l                                      ӴӞӴӈӴrӴ\Ӵ                                             +jL  h\_ h0 CJ$ OJ QJ UaJ$ +jK  h\_ h0 CJ$ OJ QJ UaJ$ +j6K  h\_ h0 CJ$ OJ QJ UaJ$ +jH  h\_ h0 CJ$ OJ QJ UaJ$ %j    h\_ h0 CJ$ OJ QJ UaJ$ hY CJ$ OJ QJ aJ$  h\_ h0 CJ$ OJ QJ aJ$  h\_ h0 5CJ$ OJ QJ aJ$ hY 5CJ$ OJ QJ aJ$        
      !  #  8  9  G  H  I  `  a  o  p  q                      ǻǫǈr\F +jR  h\_ h0 CJ$ OJ QJ UaJ$ +jP  h\_ h0 CJ$ OJ QJ UaJ$ +jO  h\_ h0 CJ$ OJ QJ UaJ$ +j5N  h\_ h0 CJ$ OJ QJ UaJ$ hY 5CJ$ OJ QJ aJ$ h\_ h0 5CJ$ OJ QJ aJ$ hY CJ$ OJ QJ aJ$  h\_ h0 CJ$ OJ QJ aJ$  %j    h\_ h0 CJ$ OJ QJ UaJ$ +j(M  h\_ h0 CJ$ OJ QJ UaJ$      8  `        j                                                                                                                                                                                                                                               	  $If   gdY i  kdM  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb  	           .  /  0  j  k  y  z  {                                    ss`Q             h\_ h\_ CJ$ OJ QJ aJ$  %j    h\_ h\_ CJ$ OJ QJ UaJ$ hY 5CJ$ OJ QJ aJ$ h\_ h\_ 5CJ$ OJ QJ aJ$ +jGU  h\_ h0 CJ$ OJ QJ UaJ$ +jeT  h\_ h0 CJ$ OJ QJ UaJ$ +jS  h\_ h0 CJ$ OJ QJ UaJ$ %j    h\_ h0 CJ$ OJ QJ UaJ$ hY CJ$ OJ QJ aJ$  h\_ h0 CJ$ OJ QJ aJ$         :  p                                                                                                                                                                                                                                                            	  $If   gdY i  kd!V  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb            $  %  &  :  ;  I  J  K  p  q                              ǱǛǅuhuhuR                    +jwZ  h\_ h\_ CJ$ OJ QJ UaJ$ hY 5CJ$ OJ QJ aJ$ h\_ h\_ 5CJ$ OJ QJ aJ$ +jpY  h\_ h\_ CJ$ OJ QJ UaJ$ +jvX  h\_ h\_ CJ$ OJ QJ UaJ$ +jW  h\_ h\_ CJ$ OJ QJ UaJ$ h\_ h\_ CJ$ OJ QJ aJ$  %j    h\_ h\_ CJ$ OJ QJ UaJ$ +jvV  h\_ h\_ CJ$ OJ QJ UaJ$        @  j      "                          |                                                                                                                                                                                           `$If   ^``gdfld 	  $If   gdY i  kd"Z  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb          	  
  0  2  @  A  O  P  Q  j  k  y  z  {                              nY                   (j    h\_ h\_ >*CJ$ OJ QJ UaJ$  +j_  h\_ h\_ CJ$ OJ QJ UaJ$ +j^  h\_ h\_ CJ$ OJ QJ UaJ$ +j]  h\_ h\_ CJ$ OJ QJ UaJ$ +j)]  h\_ h\_ CJ$ OJ QJ UaJ$ %j    h\_ h\_ CJ$ OJ QJ UaJ$ h CJ$ OJ QJ aJ$  h\_ h\_ CJ$ OJ QJ aJ$  hY CJ$ OJ QJ aJ$              $  2  6  J  L  h  j  l            V  ¨|iSii=i                       +jd  h\_ h\_ CJ$ OJ QJ UaJ$ +jb  h\_ h\_ CJ$ OJ QJ UaJ$ %j    h\_ h\_ CJ$ OJ QJ UaJ$ hY 5CJ$ OJ QJ aJ$ h\_ h\_ 5CJ$ OJ QJ aJ$ h\_ h\_ CJ$ OJ QJ aJ$  3j    h\_ h\_ >*CJ$ OJ QJ UaJ$ mH nH u(j    h\_ h\_ >*CJ$ OJ QJ UaJ$  .ja  h\_ h\_ >*CJ$ OJ QJ UaJ$  h\_ h\_ >*CJ$ OJ QJ aJ$  "  $  J      !   K   m            !  I!  !                                      |                                                                                                                                                 `$If   ^``gdE}L 	  $If   gdY i  kd-b  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb  V  Z                          !   "   0   1   2   K   L   Z   [   \   m   n   |   }   ~                     kU +jbi  h\_ h\_ CJ$ OJ QJ UaJ$ +jh  h\_ h\_ CJ$ OJ QJ UaJ$ +jg  h\_ h\_ CJ$ OJ QJ UaJ$ +jg  h\_ h\_ CJ$ OJ QJ UaJ$ h\_ hY CJ$ OJ QJ aJ$  +je  h\_ h\_ CJ$ OJ QJ UaJ$ %j    h\_ h\_ CJ$ OJ QJ UaJ$ h\_ h\_ CJ$ OJ QJ aJ$  hY CJ$ OJ QJ aJ$ !                                    !  !  "!  #!  $!  I!  J!  X!  Y!  Z!  m!  q!  !  !  !  !  !  !  !  !  !  !  !  ݱݛ݅vfYfYfYfYfY    hY 5CJ$ OJ QJ aJ$ h\_ h\_ 5CJ$ OJ QJ aJ$ h\_ hiPj CJ$ OJ QJ aJ$  +jl  h\_ h\_ CJ$ OJ QJ UaJ$ +jk  h\_ h\_ CJ$ OJ QJ UaJ$ +jj  h\_ h\_ CJ$ OJ QJ UaJ$ +j4j  h\_ h\_ CJ$ OJ QJ UaJ$ h\_ h\_ CJ$ OJ QJ aJ$  %j    h\_ h\_ CJ$ OJ QJ UaJ$  "!  !  ("  _"                                                                                                                                                                                                                                                                       x $If   gd\_ i  kdm  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb  !  ("  )"  7"  8"  9"  ;"  I"  J"  X"  Y"  Z"  ^"  _"  `"  a"  b"  c"  8#  :#  B#  C#  #  ﳠﳆ{jYHY:Y  hY @CJ" OJ QJ aJ"   hY hY @CJ" OJ QJ aJ"   hY hb @CJ" OJ QJ aJ"   h hb @CJ$ OJ QJ aJ$  h h CJ aJ  h  +jp  h\_ h\_ CJ$ OJ QJ UaJ$ %j    h\_ h\_ CJ$ OJ QJ UaJ$ h\_ h\_ CJ$ OJ QJ aJ$  .j7n  h\_ h\_ 5CJ$ OJ QJ UaJ$  (j    h\_ h\_ 5CJ$ OJ QJ UaJ$  h\_ h\_ 5CJ$ OJ QJ aJ$  _"  `"  b"      :                                                    w            w                                                                                                                                                	  $If   gdY    $If   ` gdY     ` gdY i  kdMq  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb  #  #  $  $  z$  {$  $  $  %  %  %  %         #  %  /  0  <  =  ͉  ω    *  R  T          ,  -            ̋           <  >  V  X  q  s  
    Ὣ                   h hb @CJ$ OJ QJ aJ$  #hY hY 5@CJ" OJ QJ aJ" #hY hb 5@CJ" OJ QJ aJ"  hY h @CJ" OJ QJ aJ"  U hY hY @CJ" OJ QJ aJ"   hY hb @CJ" OJ QJ aJ"  hY @CJ" OJ QJ aJ" 2The provision of services is dependent upon my eligibility for the services and upon the availability of Federal and State funds to meet the cost of services.I have right of appeal if my application is denied or if it is not acted upon promptly. I have the right to an administrative review. I may exercise this option by putting my request in writing to the District Supervisor of the local Rehabilitation Services for the Blind office, at the address below. In addition, Missouri Protection and Advocacy Services operates a Client Assistance Program which may be of interest and help to me. The Client Assistance Program provides several services including assistance in pursuing legal, administrative, or other solutions to protect my rights under the Rehabilitation Act of 1973, as amended. They also provide information about other agencies and programs in Missouri which offer rehabilitation services to persons with disabilities. The Client Assistance Program is available by writing or telephoning: Missouri Protection and Advocacy Services, 925 South Country Club Drive, Jefferson City, MO 65109, Telephone: 1-800-392-8667. I can obtain further information on my rights to appeal by contacting the RSB representative whose name, address, and telephone number are shown below.Missouri Rehabilitation Services for the Blind FORMTEXT                                                                                                                                                                                                  R S B   R e p r e s e n t a t i v e     F O R M T E X T            T e l e p h o n e   N u m b e r     F O R M T E X T             A p p l i c a n t   S i g n a t u r e   D a t e     F O R M T E X T                          M O   8 8 6 - 4 0 0 3   L P   2 / 0 8                                                                                                                                                               P a g e      P A G E      :  ;  E  F     
      6  8  L  N  P  Z  \  ^        ǯؔ}c}G}}                                           7j    h hb 5@CJ$ OJ QJ UaJ$ mH nH u2js  h hb 5@CJ$ OJ QJ UaJ$  ,j    h hb 5@CJ$ OJ QJ UaJ$  4j    h hb @CJ$ OJ QJ UaJ$ mH nH u /jq  h hb @CJ$ OJ QJ UaJ$  h hb @CJ$ OJ QJ aJ$  )j    h hb @CJ$ OJ QJ UaJ$ #h hb 5@CJ$ OJ QJ aJ$      6  ^                                                                                                                                                                                                                                                                   	  $If   gd i  kdr  $$If                 m+ +                
t  0                              +                4   4 
 a  ytb              Ў  Ҏ  Ԏ  ܎  ގ                
                "  ϳϢ~~~dϳϢYQMQMQMQM                    hR  j    hR UhY hl CJ aJ  2jnu  h hb 5@CJ$ OJ QJ UaJ$  #h hb 5@CJ$ OJ QJ aJ$ #h h 5@CJ$ OJ QJ aJ$  h hb @CJ$ OJ QJ aJ$  7j    h hb 5@CJ$ OJ QJ UaJ$ mH nH u,j    h hb 5@CJ$ OJ QJ UaJ$  2js  h hb 5@CJ$ OJ QJ UaJ$     Ҏ  Ԏ  ގ                z            z            z            z                                                                                                                                                                       	  $If   gd |  kdu  $$If                0 4m+ Q                 9                
t  0                              +                            4   4 
 a  yt      
                 "                    |            z            z            z            z            z            z            z            z            x            z            z                                   < gdY |  kd8v  $$If                0 4m+ Q                 9                
t  0                              +                            4   4 
 a  yt  "  H                                        ֳֳ񜘍                                                                                                                                                                                       hY hl CJ aJ  hR  hfld  !h+ CJ OJ QJ aJ mH nH uUj    hE}L CJ OJ QJ UaJ %j    hE}L hE}L CJ OJ QJ UaJ hE}L hE}L CJ OJ QJ aJ  hE}L CJ OJ QJ aJ  h hfld CJ OJ QJ aJ 1 of  NUMPAGES 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      < gdY  6 &P 1h:p / =!@"@#h$h%    h                                                                                                                                                                                                                                                                                                                                                                                                                                                                          D d       
             6B8. ,                                  0   
      
  #    A              b J  6Qwogz	 &     D       n  6Qwogz	PNG

   IHDR        3]F   gAMA  |Q   	pHYs  Y  Zrv  IDAThޭoIvǫ,L0`q:`8,	/PPf@;6X,IffH{=tX;^_^Ո̻`G0o>y$gٿ\~8U\l>(dwQyvw>Lncf]_GA왲X{zH7mM:sbz!1ϵmSI)M}lb"ʢ8X|Ѿc;A*Ve E/kQvLкH]3	1q\zCH/[f^XUXG1ND!0WsP@N*IxLƉQ4cnuhYAi`gt0G{s;LgA<.ӛfy5^=et#-2Ҭ$]xc
W~&5r)-LȻ($7&^Y@CLXr
@u
:1?n0<S(nN?c2(oL1=0W:6ʚ٦lN$/a?wmO+fM?,g1dvS<ϰ=;EXӹoT*,~-:mk5ugqѱm2bOPYˮ)?n!Q#c曛LOڇo6th)E>lIn - WжSQ[mBCRȋtnkpGOf[HuaOCݺ>nu	SbAy.bL?SΎj])5ptbX%yNǼmAY8Ój_;sCe{gu&7A<
VfFaq5.9ZEc/z>6JLjs9eX1j15"(, eb|NgTPTl­얁FeD(UƋ)ȭg	M^\5S2 fNb@җ_tLI+s`yiQ)YdZRBP*9RFxm\Od<yNψL0/)"$g0Ekzbh[@>S*_"0/I4:-İ\1=1x|5'̠DwZ4?cr`^22+<6wT6IR\L;IR[@S>g5g
(o`=mUD32%ILİ Dl
ܝU)f	d<cݞK9A1]EYi]j<	\f^4
-zIi.[D
ҤPnbvʙXI9&CZ	
*RA<F645LJ2V6Tab8QsiqZ8q"m Oz|U o;0<>)KmL">0*|u)\*xaJ1/E\ߕ1/ǈ]2Y:=EʛA;T9xZ%׆mA;i2ъqְ_k6yeMgyx<G	7}3bT2oSP	a'WTb:ݕeд4C>MGvsb5eɡٹx LUsb$y&Mʞ9C!VX005f s'NDYHf9]'Vr|)QX~JvL-pUE1Nl9<:CuRW}rugy*<7QĨ1_GЗzИlBe<ucK[?$3U?u{Y'ӠF0ckA9	;:ERM`W=0gW}I9٘fᯙFeV>_O~Mv3[A	f4\>FΌČyb̔dH\r)8Oϧ4{&g&y}&lmAcGH$E}*/-jxEzL(Kcn:.0NɭH80;<g#7[Htfx%Zf'jvw}0ܖgA׺S$8ZBz8^`T=Iȑa1矟'STP*x?Ȏ.O*ĘΉ􊗽RQda#GYk?bl<}Wi3)V{02-r|X{eE/~oy@=8߬ikϯrgL@{*Ec,XR(wD^fsLPT)&"Px'H=P+fWtL8by-RO+vFr#R]c/iƮ7Ŧ1Ue-T2.oRycTlau_4+y{
5 u6o[Xj|<g̵[m3SjʦΈm[XC)򵠪cFL=,\(rf<3(쩠}#dO)0jbw@we81`'/8?H(;>^KʒȨI8BT.gQ7dgOC%͐?64F/cP9m0Kn{\1+YSc-P0DL-R#([C3|N~3V"Gs&&Pȉ_mU7|JLsnu2<vn)P#21NaOA=(vĈI\ƥz-v08AD*Gߔ/vrUE1;۳W4}1\|^ DE]fzy$bZNYGʖ]J&ڔf11 Nk-Cѳm޶W=fBeXR|6ű}E9j짴]J[*RO%Y(b|>Vntc7JrjvdP<)%5"H%ubr91AI
-ieF۽J@fa*NxcTPyWߓA`8-v"uY64
sH:#:8/q#Ŗ|#Uzz`%J|_*=+gUY`ϩj~jl,˦ A;(hRt}3TJj5G&Y[#}^s2 xlaQ4{4Ybv%zsft+D7NN7X D|fiae>/Aa9veZ͗|lbAL2ĎE{ =Js5tHgCX)We-j1(g_1FY/ݺU-N"=}Ĕdcײ=?P(̝d(8댦 :yzYN`M9nZdqlD:d4F^ sb'|8A8/R2&`)9n3t5uKAGYb(ľ*O׎!\L:Z㈁r>{T|sH{D%&lKAW|PiKR%v7t\a=/'j)OQkGރQidZaȼ%ҨOw#/RӪ{HH]mU.\^U:X=T]5"WNxYM/gew؜8V                        	   
                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   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   R   S   T   U   V   W   X   u   [   s      _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   p   q   r      v   w   x   y   z   {   |   }   ~         R o o t   E n t r y                                                 	           F            "/2h]          D a t a                                                         
                                     Q   v      W o r d D o c u m e n t                                                                                     8      O b j e c t P o o l                                                                        L/2h"/2h            _ 1 1 7 3 5 2 0 1 5 2                                               PRP '    L/2h ӹ/2h             O l e                                                         
                                         7        W P G 2 0                                                                                                ^   (       C o m p O b j                                                                                         }                	   
                                     '               F   ! 	   WP 7 [0]           
  PRP '   Corel Presentations 10 Drawing    Embed Source    Presentations.Drawing.10 9q                                                                                F     H                                                 F   H   d                                                                             Oh +'0                                                        	     WPC           (         -.    -. 5   1   3     9 X!      -.    b(   	  0                     	              C             (                                       F F 2~~00_~ <?X?9?ǎǏ|?!Ǐ <w     ?      >    >  6p0Q  8?!~<cx< uc8<?  u8 8| ?0 ??xp~?q ?  ? ?    ??            u?x       <      C??           ?   |?|<?> ?  À?   |?   ??0?  ? x  ??  0 ~  3     !  ` ? #| ?+   ? ?r  ? 	 a ?3  }~p?   ~#     8?! |u >?8    ?Ã ~    χǀ   p? ~?    Ç   ?Ç  ?     xA?C     88D  x   88`  > x  ?? ?  ?l? p >?ǀA0>??  ~ |   xp  x   Ç x     xp  8< A0> ?| ?`  > 0?`   03     L    ? ?  ??A |   >?8   ?p    `   ?1         <
 Ì 8?     |     x  0  @@ |? 8c  |` |?>`>?#`??6ó ?
? < pL?     ?? |        ?-?         ?8? x    4? 8    ? <8x?   &8<,@  >  <<$@O> 
| > ~  ?~ ?   ?<?<AO x?  N  ?     | ?      |? ?      ~s? ?      ~q 8 <     ~!u8    0 8  0? | x?<ar?? |~a? >?< ?r?  8   0     	`?   	`|  `  ?   >` `??   | `??   >?`??? ??
? g?? ??  |`Ã?  8`x? `? x<x? 08 ?~ |  c? x <   c?? p    C^? q H` 0? x 0? | 0<x?|π00????L@?? ` ?|??   ~X     Á    ? ?  qCxG3?<<G??  $8>s? <  ??< <0  ?|  | < @< ???<  ?p<?  x ?<?  >  8   ?   ?   C?   Ã ?~=      a ?  a ?u? ?0?? ?0q??  89?t ???>?x?V? ? ? ? ? ???  @ > ?? |   ?  a  ?   ??        ?          ?   ???   ?     ?  ? ? < V    ?  |?  x??   x?_? |??$  ?V?>?R? ? ? ?  8                      `   ?  ?? ?& ??|c < <?~|>     ??  u ?  s 8?? ?  ?    p Ç  >     ? ??up?u0Çp up ? >0 F 0? 0  >aa `Ï?`  ?a  p~ 0?q~  0~ ,?  ~   ???S ?  
  ?A0?v0?  ~ 3   &U3@tEV                                                                                                                                                                                                                                                                                                                O b j I n f o                                                      	                                                  B O l e P a r t                                                
                                                  W P G E x t e n t s                                                                                    
       1 T a b l e                                                                                                    z8                                                                                                                                                                                                                      8m%ֳ~kxUAɱ&`8_RPX2܍O@\3w|BnOm;4{{[K0ҝ}cO7Sdu-i}yLEtB7oGoES,^gFX>ê#§lN1a[Ōp˅/r=a_L3e>+h)|0||qӝ-6lTгM.1I4_s'/b_HM'`7N5J&Yg_N@i)	<1Vm[=SP.8N?îTzjWwRx!iWFk 8ĚUbRsV<&e
;KsmoA)(^zj9i[/#:42;n0Tty{IaCUPQ͖!?kZ!z,ޟgXw{E'=TE#ҎAЖtx)(nVw[CiwQrtn\!7WVLj!Cw)}6gfcKg0^p FϥSy5;2@Ԛޠ*ޑ<,?!YN=ğ^=V	xKJ~?P,U7W(O<]Ҷe*Qn71
#0S-ȵؿ=6ajco_!O6^\ng7'j6cemg	FQo>jmtkO7tQ0j;vnk{)̨h?wY2,g}.Vûirz;L̽.6=+tzY.s|Zǟd|s313?\ w-    IENDB`s $$If     !v h5 U55'#v U#v5':V  g
t  +  , 5 U55'4 
 yttV "  D                                                                    T e x t 1           / O   B   S   C l i e n t   N a m e    
 L a s t ,   F i r s t ,   M i d d l e   I n i t i a l   ( C L I E N T   N A M E ,   L A S T ,   F I R S T ,   M I D D L E   I N I T I A L              D                                                                    T e x t 2            O   B   S   C a s e   N u m b e r    C A S E   N U M B E R           m $$If     !v h5 5#v #v:V  Q
t  +  5 54 
 yttV    D                                                                    T e x t 3            S t r e e t   A d d r e s s    S T R E E T   A D D R E S S           W $$If     !v h5 +#v +:V  
t  +  5 +4 
 yttV    D                                                                    T e x t 4            C i t y    C I T Y              D                                                                    T e x t 5            S t a t e    S T A T E              D                                                                    T e x t 6            Z i p   C o d e    Z I P   C O D E              D                                                                    T e x t 7            C o u n t y   N a m e   a n d   C o u n t y   N u m b e r    C O U N T Y   N A M E   A N D   C O U N T Y   N U M B E R            $$If     !v h5 5855#v #v8#v#v:V  
t  +  5 58554 
 yttV    D                                                                    T e x t 8            C l i e n t   T e l e p h o n e   N u m b e r    T E L E P H O N E   N U M B E R              D                                                                    T e x t 9            S o c i a l   S e c u r i t y   N u m b e r    S O C I A L   S E C U R I T Y   N U M B E R              D                                                                    T e x t 1 0            D a t e   o f   B i r t h    D A T E   O F   B I R T H            $$If     !v h5 55#v #v#v:V  
t  +  5 554 
 ytb    D                                                                    T e x t 1 1            R e f e r r a l   D a t e    R E F E R R A L   D A T E              D                                                                    T e x t 1 3            A p p l i c a t i o n   D a t e    A P P L I C A T I O N   D A T E              D                                                                    T e x t 1 2            C a s e   l o a d   N u m b e r    C A S E L O A D   N U M B E R           q $$If     !v h5 %5%5@#v %#v@:V  
t  +  5 %5@4 
 ytb    D                                                                    T e x t 1 4            P r e v i o u s   O   B   S   C a s e    P R E V I O U S   O B S   C A S E           H  D                                                                    T e x t 1 5           > I f   c l i e n t   h a d   a     p r e v i o u s   O   B   S   c a s e   w h a t   w a s   t h e   c l o s u r e   d a t e   + I F   Y E S   T O   P R E V I O U S   C A S E ,   E N T E R   C L O S U R E   D A T E           [ $$If     !v h5 5#v :V  
t  +  5 4 
 ytiPj    D                                                                    T e x t 1 6            D a t e   o f   E l i g i b i l i t y    D A T E   O F   E L I G I B I L I T Y              D                                                                   C h e c k 1          G E N D E R   M A L E    G E N D E R   M A L E              D                                                                   C h e c k 2          F E M A L E    F E M A L E           [ $$If     !v h5 5#v :V  
t  +  5 4 
 ytiPj    D                                                                   C h e c k 3          R a c e   W h i t e   N o n   H i s p a n i c    R A C E   W H I T E   N O N H I S P A N I C              D                                                                   C h e c k 4          A f r i c a n - A m e r i c a n   N o n   H i s p a n i c    A F R I C A N   A M E R I C A N   N O N H I S P A N I C              D                                                                   C h e c k 5         ! A m e r i c a n   I n d i a n   o r   A l a s k a n   N a t i v e   ! A M E R I C A N   I N D I A N   O R   A L A S K A N   N A T I V E              D                                                                   C h e c k 6          A s i a n    A S I A N             D                                                                   C h e c k 7         ) H a w a i i a n   N a t i v e   o r   O t h e r   P a c i f i c   I s l a n d e r   ) H A W A I I A N   N A T I V E   O R   O T H E R   P A C I F I C   I S L A N D E R              D                                                                   C h e c k 8          H i s p a n i c   o r   L a t i n o    H I S P A N I C   O R   L A T I N O             D                                                                   C h e c k 9         * O T H E R   R A C E / E T H N I C I T Y   N O T   P R E V I O U S L Y   L I S T E D   * O T H E R   R A C E / E T H N I C I T Y   N O T   P R E V I O U S L Y   L I S T E D              D                                                                    T e x t 1 7            I f   o t h e r   r a c e ,   p l e a s e   s p e c i f y    I F   O T H E R   R A C E ,   P L E A S E   S P E C I F Y           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb r  D                                                                   C h e c k 1 0         N V i s u a l   D i s a b i l i t y  
 T o t a l y   B l i n d    
 L i g h t   P e r c e p t i o n   O n l y   o r   N o   L i g h t   P e r c e p t i o n   0 V I S U A L   D I S A B I L I T Y   T O T A L L Y   B L I N D   L P   O N L Y   O R   N O   L P             D                                                                   C h e c k 1 1         ' L e g a l l y   B l i n d   E x c l u d i n g   t o t a l   b l i n d n e s s   ' L E G A L L Y   B L I N D   E X C L U D I N G   T O T A L   B L I N D N E S S           4  D                                                                    T e x t 1 8           1 I f   L e g a l l y   B l i n d ,   S p e c i f y   R e p o r t e d / S n e l l e n   A c u i t y   . I F   L E G A L L Y   B L I N D   E N T E R   R E P O R T E D   S N E L L E N   A C U I T Y             D                                                                   C h e c k 1 2         E P r o g r e s s i v e   C o n d i t i o n  
 2 0   o v e r   7 0   o r   w o r s e   c o r r e c t e d   b i l a t e r a l   a c u i t y   D P R O G R E S S I V E   C O N D I T I O N   2 0   O V E R   7 0   O R   W O R S E   C O R R E C T E D   B I L A T E R A L   A C U I T Y           d  D                                                                    T e x t 1 9           @ I f   p r o g r e s s i v e   c o n d i t i o n ,   p l e a s e   s p e c i f y   r e p o r t e d / s n e l l e n   a c u i t y   7 I F   P R O G R E S S I V E   C O N D I T I O N ,   E N T E R   R E P O R T E D   S N E L L E N   A C U I T Y           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb   D                                                                   C h e c k 1 3         T M a j o r   C a u s e   o f   V i s u a l   I m p a i r m e n t   A s   r e p o r t e d   b y   t h e   i n d i v i d u a l  
 M a c u l a r   D e g e n e r a t i o n   U M A J O R   C A U S E   O F   V I S U A L   I M P A I R M E N T S   A S   R E P O R T E D   B Y   T H E   I N D I V I D U A L     M A C U L A R   D E G E N E R A T I O N              D                                                                   C h e c k 1 4          D i a b e t i c   R e t i n o p a t h y    D I A B E T I C   R E T I N O P A T H Y              D                                                                   C h e c k 1 5          G l a u c o m a    G L A U C O M A              D                                                                   C h e c k 1 6         	 C a t a r a c t s   	 C A T A R A C T S           *  D                                                                   C h e c k 1 7         - O t h e r   v i s u a l   i m p a i r m e n t   n o t   p r e v i o u s l y   l i s t e d   - O T H E R   V I S U A L   I M P A I R M E N T   N O T   P R E V I O U S L Y   L I S T E D           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb `  D                                                                   C h e c k 1 8          N o n   v i s u a l   i m p a i r m e n t s / c o n d i t i o n s   a t   t h e   t i m e   o f   i n t a k e   a s   s t a t e d   b y   t h e   i n d i v i d u a l  
 C h e c k   O n e   i f   a p p l i c a b l e  
 H e a r i n g   I m p a i r m e n t   u N O N V I S U A L   I M P A I R M E N T S / C O N D I T I O N S   A T   I N T A K E   A S   R E P O R T E D   B Y   T H E   I N D I V I D U A L     C H E C K   O N E   I F   A P P L I C A B L E     H E A R I N G   I M P A I R M E N T             D                                                                   C h e c k 1 9          M e n t a l   I m p a i r m e n t s   i n c l u d i n g   c o g n i t i v e   i m p a i r m e n t s ,   l e a r n i n g ,   t h i n k i n g ,   p r o c e s s i n g   i n f o r m a t i o n   a n d   c o n c e n t r a t i o n ,   p s y c h o s o c i a l   i m p a i r m e n t s ,   p e r s o n a l   a n d   b e h a v i o r   i m p a i r m e n t s ,   d i f f i c u l t y   c o p i n g ,   a l z h e i m e r ' s   a n d   o t h e r   m e n t a l   i m p a i r m e n t s .   2 M E N T A L   I M P A I R M E N T     P R E S S   F 1   H E L P   K E Y   F O R   S P E C I F I C S              D                                                                   C h e c k 2 0          C a n c e r    C A N C E R           N  D                                                                   C h e c k 2 1         6 C a r d i a c   a n d   o t h e r   c o n d i t i o n s   o f   t h e   c i r c u l a t o r y   s y s t e m   6 C A R D I A C   A N D   O T H E R   C O N D I T I O N S   O F   T H E   C I R C U L A T O R Y   S Y S T E M              D                                                                   C h e c k 2 2          D i a b e t e s   M e l l i t i s    D I A B E T E S   M E L L I T U S           >  D                                                                   C h e c k 2 3         2 E n d   s t a g e   r e n a l   d i s e a s e   a n d   g e n i t o u - u r i n a r y   s y s t e m   2 E N D   S T A G E   R E N A L   D I S E A S E   A N D   G E N I T O U   U R I N A R Y   S Y S T E M             D                                                                   C h e c k 2 4          M u s c u l o s k e t a l   s u c h   a s   a r t h r i t i s ,   r h e u m a t i s m ,   a m p u t a t i o n s ,   f r a c t u r e s / i n j u r i e s   w h i c h   r e s u l t e d   i n   p e r m a n e n a n t   l o s s / i m p a i r m e n t   o f   l i m b   f u n c t i o n   8 M U S C U L O S K E T A L   C O N D I T I O N S   P R E S S   F 1   H E L P   K E Y   F O R   S P E C I F I C S             D                                                                   C h e c k 2 5          N e u r o l o g i c a l   i m p a i r m e n t s / d i s o r d e r s   d u e   t o   S t r o k e   C V A   w i t h   r e s u l t i n g   p a r a l y s i s   o r   w e a k n e s s ,   p e r i p h e r a l   o r   d i a b e t i c   n e u r o p a t h y ,   c o n d i t i o n s   a f f e c t i n g   t h e   c e n t r a l   n e r v o u s   s y s t e m   i n c l u d i n g   p a r k i n s o n ' s ,   s e i z u r e   d i s o r d e r s ,   c e r b r a l   p a l s y ,   m u l t i p l e   s c h l e r o s i s ,   e t c   B N E U R O L O G I C A L   I M P A I R M E N T S / D I S O R D E R S   P R E S S   F 1   H E L P   K E Y   F O R   S P E C I F I C S              D                                                                   C h e c k 2 6          R e s p i r a t o r y   o r   l u n g   c o n d i t i o n s    R E S P I R A T O R Y   O R   L U N G   C O N D I T I O N S           R  D                                                                   C h e c k 2 7         1 O t h e r   n o n   v i s u a l   i m p a i r m e n t   n o t   p r e v i o u s l y   l i s t e d   = O T H E R   N O N V I S U A L   I M P A I R M E N T   O R   C O N D I T I O N   N O T   P R E V I O U S L Y   L I S T E D           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb   D                                                                   C h e c k 2 8          O n s e t   o f   s i g n i f i c a n t   v i s i o n   l o s s .      
 W h e n   l o s s   b e g a n   t o   a f f e c t   p e r f o r m a n c e   o f   d a i l y   a c t i v i t i e s  
  
 L e s s   t h a n   1   y e a r   b e f o r e   i n d e p e n d e n t   l i v i n g   s e r v i c e s    O N S E T   O F   S I G N I F I C A N T   V I S I O N   L O S S ,   W H E N   L O S S   B E G A N   T O   A F F E C T   P E R F O R M A N C E   O F   D A I L Y   A C T I V I T I E S   L E S S   T H A N   1   Y E A R   B E F O R E   I L   S E R V I C E S              D                                                                   C h e c k 2 9          1   t o   3   y e a r s    1   T O   3   Y E A R S              D                                                                   C h e c k 3 0          4   t o   6   y e a r s    4   T O   6   Y E A R S              D                                                                   C h e c k 3 1          7   t o   9   y e a r s    7   T O   9   Y E A R S              D                                                                   C h e c k 3 2          T e n   y e a r s   o r   m o r e    1 0   Y E A R S   O R   M O R E           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb Z  D                                                                   C h e c k 3 3         9 H i g h e s t   l e v e l   o f   e d u c a t i o n   c o m p l e t e d  
 N o   f o r m a l   s c h o o l i n g   9 H I G H E S T   L E V E L   O F   E D U C A T I O N   C O M P L E T E D     N O   F O R M A L   S C H O O L I N G             D                                                                   C h e c k 3 4         ' E l e m e n t a r y   E d u c a t i o n   G r a d e s   1   t h r o u g h   8   $ E L E M E N T A R Y   E D U C A T I O N   G R A D E S   1   T H R U   8           v  D                                                                   C h e c k 3 5         C S e c o n d a r y   e d u c a t i o n ,   n o   h i g h   s c h o o l   d i p l o m a   g r a d e s   9   t h r o u g h   t w e l v e   = S E C O N D A R Y   E D U C A T I O N ,   N O   H I G H   S C H O O L   D I P L O M A ,   G R A D E S   9   T H R U   1 2             D                                                                   C h e c k 3 6         & H i g h   S c h o o l   o r   e q u i v a l e n c y   c e r t i f i c a t e   & H I G H   S C H O O L   O R   E Q U I V A L E N C Y   C E R T I F I C A T E           F  D                                                                   C h e c k 3 7         4 P o s t   s e c o n d a r y   e d u c a t i o n   l e s s   t h a n   b a c h e l o r ' s   d e g r e e   4 P O S T   S E C O N D A R Y   E D U C A T I O N   L E S S   T H A N   B A C H E L O R ' S   D E G R E E              D                                                                   C h e c k 3 8          B a c h e l o r ' s   d e g r e e   o r   h i g h e r    B A C H E L O R ' S   D E G R E E   O R   H I G H E R              D                                                                   C h e c k 3 9          M a s t e r ' s   d e g r e e   o r   h i g h e r    M A S T E R ' S   D E G R E E   O R   H I G H E R           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb J  D                                                                   C h e c k 4 0         : T y p e   o f   l i v i n g   a r r a n g e m e n t   a t   t i m e   o f   i n t a k e  
 L i v i n g   a l o n e   0 T Y P E   O F   L I V I N G   A R R A N G E M E N T   A T   I N T A K E     L I V E   A L O N E              D                                                                   C h e c k 4 1          L i v e   w i t h   s p o u s e    L I V E   W I T H   S P O U S E              D                                                                   C h e c k 4 2         ! L i v e   w i t h   p e r s o n a l   c a r e   a s s i s t a n t   ! L I V E   W I T H   P E R S O N A L   C A R E   A S S I S T A N T              D                                                                   C h e c k 4 3          L i v e   w i t h   o t h e r    L I V E   W I T H   O T H E R           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb   D                                                                   C h e c k 4 4          S e t t i n g   o f   r e s i d e n c e   a t   t i m e   o f   i n t a k e  
 P r i v a t e   r e s i d e n c e   a p a r e m e n t   o r   h o m e   a l o n e ,   o r   w i t h   r o o m m a t e ,   p e r s o n a l   c a r e   a s s i s t a n t ,   f a m i l y   o r   o t h e r   p e r s o n    S E T T I N G   O F   R E S I D E N C E   A T   T I M E   O F   I N T A K E     P R I V A T E   R E S I D E N C E ,   A P A R T M E N T ,   H O M E   A L O N E ,   R O O M M A T E ,   P E R S O N A L   C A R E   A S S I S T A N T ,   F A M I L Y   O R   O T H E R   P E R S O              D                                                                   C h e c k 4 5          C o m m u n i t y   r e s i d e n t i a l    C O M M U N I T Y   R E S I D E N T I A L              D                                                                   C h e c k 4 6          A s s i s t e d   l i v i n g   c e n t e r    A S S I S T E D   L I V I N G   C E N T E R             D                                                                   C h e c k 4 7         ' N u r s i n g   h o m e   o r   l o n g   t e r m   c a r e   f a c i l i t y   ' N U R S I N G   H O M E   O R   L O N G   T E R M   C A R E   F A C I L I T Y           2  D                                                                   C h e c k 4 8         / O T H E R   R E S I D E N T I A L   S E T T I N G   N O T   P R E V I O U S L Y   L I S T E D   / O T H E R   R E S I D E N T I A L   S E T T I N G   N O T   P R E V I O U S L Y   L I S T E D           (  D                                                                    T e x t 2 0           - I f   o t h e r   r e s i d e n t i a l   s e t t i n g ,   p l e a s e   s p e c i f y     , I F   O T H E R   R E S I D E N T I A L   S E T T I N G ,   P L E A S E   S P E C I F Y           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb   D                                                                   C h e c k 4 9         B S o u r c e   o f   r e f e r r a l  
 E y e   c a r e   p r o v i d e r ,   o p t h a l m o l o g i s t ,   o p t o m e t r i s t   C S O U R C E   O F   R E F E R R A L     E Y E   C A R E   P R O V I D E R ,   O P H T H A L M O L O G I S T ,   O P T O M E T R I S T             D                                                                   C h e c k 5 0         ^ G e n e r a l   p r a c t i t i o n e r ,   p r i m a r y   c a r e   p r o v i d e r ,   o r   o t h e r   m e d i c a l   p e r s o n n e l   o r   m e d i c a l   i n s t i t u t i o n   [ G E N E R A L   P R A C T I T I O N E R ,   P R I M A R Y   C A R E   P R O V I D E R ,   O T H E R   M E D I C A L   P E R S O N N E L   O R   M E D I C A L   I N S T I T U T I O N           2  D                                                                   C h e c k 5 1         / S t a t e   V R   a g e n c y   c o u n s e l o r   o r   o t h e r   a g e n c y   s t a f f   / S T A T E   V R   A G E N C Y   C O U N S E L O R   O R   O T H E R   A G E N C Y   S T A F F              D                                                                   C h e c k 5 2          S o c i a l   S e r v i c e   A g e n c y    S O C I A L   S E R V I C E   A G E N C Y              D                                                                   C h e c k 5 3          S e l f   r e f e r r a l    S E L F   R E F E R R A L              D                                                                   C h e c k 5 4          F a m i l y   m e m b e r   o r   f r i e n d    F A M I L Y   M E M B E R   O R   F R I E N D              D                                                                   C h e c k 5 5          V e t e r a n s   a d m i n i s t r a t i o n    V E T E R A N S   A D M I N I S T R A T I O N              D                                                                   C h e c k 5 6          S e n i o r   p r o g r a m    S E N I O R   P R O G R A M              D                                                                   C h e c k 5 7          R e l i g i o u s   o r g a n i z a t i o n    R E L I G I O U S   O R G A N I Z A T I O N              D                                                                   C h e c k 5 8           C o m m u n i t y   r e h a b i l i t a t i o n   p r o g r a m     C O M M U N I T Y   R E H A B I L I T A T I O N   P R O G R A M           <  D                                                                   C h e c k 5 9         1 o t h e r   s o u r c e s   s u c h   a s   p u b l i c   s e r v i c e   a n n o u n c e m e n t   2 O T H E R   S O U R C E S ,   S U C H   A S   P U B L I C   S E R V I C E   A N N O U N C E M E N T           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb   D                                                                   C h e c k 6 0          D o   y o u   f e e l   a f t e r   d i s c u s s i o n   o f   t h e   s e r v i c e s   o f f e r e d   b y   r e h a b i l i t a t i o n   s e r v i c e s   f o r   t h e   b l i n d ,   t h a t   y o u r   h e a l t h   w i l l   a l l o w   y o u   t o   b e   m o r e   i n d e p e n d e n t  
 Y e s   w D O   Y O U   F E E L   A F T E R   D I S C U S S I O N   O F   T H E   S E R V I C E S   O F F E R E D   B Y   R S B   T H A T   Y O U R   H E A L T H   W I L L   A L L O W   Y O U   T O   B E   M O R E   I N D E P E N D E N T     Y E S           ~   D                                                                   C h e c k 6 1          N o    N O           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb $  D                                                                    T e x t 2 3           . E n t e r   D i s t r i c t   O f f i c e   c i t y ,   s t a t e   a n d   z i p   c o d e   ) E N T E R   D I S T R I C T   O F F I C E   C I T Y ,   S T A T E   A N D   Z I P           S $$If     !v h5 +#v +:V  
t  +  5 +4 
 ytb    D                                                                    T e x t 2 4            R   S   B   R e p r e s e n t a t i v e   N a m e    R S B   r e p r e s e n t a t i v e   n a m e             D                                                                    T e x t 2 5           ( T e l e p h o n e   n u m b e r   o f   R   S   B   R e p r e s e n t a t i v e   & t e l e p h o n e   n u m b e r   o r   R S B   r e p r e s e n t a t i v e           i $$If     !v h5 Q59#v Q#v9:V  
t  +  5 Q594 
 yt    D                                                                    T e x t 2 6            D A T E   S I G N E D   B Y   C L I E N T    D A T E   S I G N E D   B Y   C L I E N T           i $$If     !v h5 Q59#v Q#v9:V  
t  +  5 Q594 
 yt                                                                                                                                                                                                                                                                                                                                                               S u m m a r y I n f o r m a t i o n                           (                                                     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                                        <       C o m p O b j                                                                                          q                                                                                                                                
   <     H     T     `     l     t     |                                      Stacey L. Schulte                             Normal.dot        SCHUMAN       3         Microsoft Office Word   @       @    ,h@    &h@    )0h         Q                                        ՜. +,0           h      p                                                                       (   Missouri Department of Social Services     4                 '                                                  Title            
  	           F   Microsoft Office Word Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          L  @ L          N o r m a l      $ CJ OJ QJ ^J _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          : %@  :   =    E n v e l o p e   R e t u r n       d $@ d   rT    E n v e l o p e   A d d r e s s   !  @&+D/ ^@  CJ  aJ  j @ j   |a/   
 T a b l e   G r i d   7 :V 0                                   4 @ "4   tV    H e a d e r      !   4  @ 24   tV    F o o t e r      !   . )@ A.   E}L    P a g e   N u m b e r                     &   g                               
    $  8  <  P  ]  q  r  |                    +  6  J  K  ]  q                    @  t        )  a  b        6          $  M  j          (  O  s        F	  	  	  <  W  X        )  G  l  m        >  y      "  #  P  o                  +  k  l      7  {          B  m                  ,  [  o  p                                        }    @   0                 @   0                  @   0                  @   0                 @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                 @   0                  @   0                  @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                  @   0                  @   0                 @   0                 @   0                  @   0                 @   0                  @   0                  @   0                  @   0                 @   0                 @   0                 @   0                 @   0                 @   0                  @   0                  @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                  @   0                  @   0                 @   0                 @   0                 @   0                 @   0                 @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                 @   0                 @   0                 @   0                 @   0                 @   0                  @   0                  @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                 @   0                  @   0                  @   0                  @   0                  @   0                    @   0                  @   0                 @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                  @   0                     0 0                   0 0                    0 0                   0 0                    0 0                    0 0                    0 0                    0 0                   @  0                    0 0                 
    &                               
    $  8  <  P  ]  q  r  |                    +  6  J  ]        <  W  X  l  m  "  #        k  l          ,  [  o  p             0 0                   0 0                   0 0                  00                  00                  00                  00                  00                  00                  00                  00                  00                   00                   00                   00                   00                   00                   00                   00                   00                  0$0                   0$0                   0$0                   0$0                   0$0                   0$0                   00                  010                   010                   010                   010                   010                   010                   010                   010                   00                   00                  0'0                  0 0                  @   0                    00                 ` @   0                  00                  @3  0                    0.0                  0
0                  0O0                  0O0            P     @   0          ;        00               `@z @I N0D E P E N D         050         	   6   ]E@R F0O R M A N C         070         	         070                  060                  00                 0 0                 z 00                 z 00               p?z 00               ?z@   0                                	                                 H	  	  :
  
  \      F    @             .    5  u              V     !  #      "                         !   #   $   &   '   )   *   +   -   .   0   1   2   4   5   7   9   ;   <   >   ?   A   C   H   J   M      	  
  
      :        H          "  !  _"                               "   %   (   ,   /   3   6   8   :   =   @   B   I   K   L   O               "   $                             
      $  0  6  <  H  N  ]  i  o  |                          #  )  6  B  H  ]  i  o                        '  @  P  t                )  9  M  Y  _          "  .  4  6  F            $  4  M  ]  j  z      (  8  O  _  s              	  F	  V	  	  	  	    <  L              )  9  G  W               >  N  y            P  `  o              &              +  ;  W  c  i          7  G  {                  /  B  R  m  }              [  g  m                      :FFFFFFFFFFFFFFFFG$G$G$G$G$G$G$G$G$FG$G$FG$FG$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$FG$G$G$G$G$G$G$G$G$G$G$G$G$FFFFs   z   |               !  8                         @                           0    (    	                    
          B    
        S              	   ?          %    T e x t 1  T e x t 2  T e x t 3  T e x t 4  T e x t 5  T e x t 6  T e x t 7  T e x t 8  T e x t 9  T e x t 1 0  T e x t 1 1  T e x t 1 3  T e x t 1 2  T e x t 1 4  T e x t 1 5  T e x t 1 6  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  T e x t 1 7  C h e c k 1 0  C h e c k 1 1  T e x t 1 8  C h e c k 1 2  T e x t 1 9  C h e c k 1 3  C h e c k 1 4  C h e c k 1 5  C h e c k 1 6  C h e c k 1 7  T e x t 2 6          
  $  <  ]  |          6  ]            @  t        )  M      "  6      $  M  j                                    	   
                                                                      !   "   #   $             7  O  p          *  I  p          (  Q          :  `      5  G      5  ^  {            /	  6	                          `  j  n  |  ~                            O  S                          `  j  n  |  ~     3                       K  K                  (  (  Q  Q                  :  :              G  G      5  5  ^  ^  {  {                  &  '  9  9  `  `                          -  .  S  T              	  	  W	  W	  	  	   
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          M  M  y  y                  :  :  X  X                      O  O              a  a              '  '                <  <          H  H                  0  0  S  S  ~  ~          '  '      o  o  '  '                          `  j  n  |                                                                                                                                                                                                          3                2   -q  & rT R W + q+, . |a/ $0 /g1 M)6 8}I E}L k9O R ,5X Y @[ i[ \_ Gcb fld Te iPj "[l F  K ] V/ Dp Y =  D ^' <o  7 UH 2V |$ l b  y 0  t: r tV     &                        8  P  q  r            +  J  K  q            a  b          W  X  l  m  "  #      k  l            o  p                                                                                                                @|          Z  Z  Z  Z  Z  !  h  h    P      P   @  P      P      P  ( @  P      P  @ @  P  @  P      P  8@      U n k n o w n                                   G  z                  T i m e s   N e w   R o m a n   5                       S y m b o l   3&  z                  A r i a l   9                       G a r a m o n d   "  1         *Ft+FW+F    Q         4   Q        4       !                                                                                                                                                                                                                                                                                                                         @h  4    d                                                                               2Q                               HX    ) ?    |a/     2                                  S t a c e y   L .   S c h u l t e  S C H U M A N                                                                                                                                                                                                                                                                                                                                                                                                                           