ࡱ                >  	               S          U          R   m    [	               t   bjbj                  	 4  ΐ ΐ                                                                                                                                                          +  2  }    M      M      M      M      (  t           *     *      *      *      *      *      *      ,    p/  @   *                           5%                      (      (      5%      5%      *                          M              M     V+     S)      S)      S)      5%  
         M            M      *              S)                                                      5%      *              S)              S)                                                                              S)      M          `              ?%     S)              *     l+  0   +      S)      /      %    /      S)                                                                              /                    S)  `  t     v!     S)      ."     "  s                                  t       t       t       *      *                                      I)  
                                   t       t       t       +      5%      5%      5%      5%                                                                                          /      t       t       t       t       t       t                                                               t       t       t         	    :     	                                                                                                                                                                                                                                                                                                                                                                                                                                         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   C O D E       F O R M T E X T            C O U N T Y   A N D   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   N U M B E R       F O R M T E X T            D A T E   O F   B I R T H   ( M O N T H ,   D A Y ,   Y E A R )       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 .   D A T E       F O R M T E X T            C A S E L O A D   N U M B E R       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    FORMCHECKBOX   (1) FEMALE              FORMCHECKBOX   (2) MALERACE/ETHNICITY FORMCHECKBOX   (1) HISPANIC/ LATINO OF ANY RACE OR HISPANIC/LATINO ONLY FORMCHECKBOX   (2) AMERICAN INDIAN OR ALASKA NATIVE FORMCHECKBOX   (3) ASIAN FORMCHECKBOX   (4) BLACK OR AFRICAN AMERICAN FORMCHECKBOX   (5) NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER FORMCHECKBOX   (6) WHITE FORMCHECKBOX   (7) TWO OR MORE RACES FORMCHECKBOX   (8)  RACE AND ETHNICITY UNKNOWN  ( Only if consumer ref u s e s   t o   i d e n t i f y )      D E G R E E   O F   V I S U A L   I M P A I R M E N T          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 )     S E V E R E   V I S U A L   I M P A I R M E N T ,   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   (   C H E C K   O N L Y   O N E   M A J O R   V I S U A L   I M P A I R M E N T   )      F O R M C H E C K B O X         (1) MACULAR DEGENERATION FORMCHECKBOX   (2) DIABETIC RETINOPATHY FORMCHECKBOX   (3) GLAUCOMA FORMCHECKBOX   (4) CATARACTS FORMCHECKBOX   (5) OTHERMO 886-4003 (10-08)                                                                                  PAGE 1                                                                                                               OBS-1OTHER AGE RELATED IMPAIRMENTS  (CHECK ALL THAT APPLY) FORMCHECKBOX   (1) HEARING IMPAIRMENT FORMCHECKBOX   (2) DIABETES FORMCHECKBOX   (3) CARDIOVASCULAR DISEASE AND STROKES FORMCHECKBOX   (4) CANCER FORMCHECKBOX   (5) BONE, MUSCLE, SKIN, JOINT, AND MOVEMENT DISORDER FORMCHECKBOX   (6) ALZHEIMER'S DISEASE/ COGNITIVE IMPAIRMENT FORMCHECKBOX   (7)  DEPRESSION/MOOD DISORDERS  FORMCHECKBOX   (8)  OTHER MAJOR GERIATRIC CONCERNSTYPES OF LIVING ARRANGEMENTS  FORMCHECKBOX  (1)  LIVES ALONE  FORMCHECKBOX  (2)  LIVES WITH OTHERS (FAMILY, SPOUSE, CARETAKER, ETC)TYPES OF RESIDENCE    FORMCHECKBOX  (1)  PRIVATE RESIDENCE (HOUSE OR APARTMENT)   FORMCHECKBOX  (2) SENIOR LIVING/RETIREMENT COMMUNITY   FORMCHECKBOX  (3) ASSISTED LIVING FACILITY   FORMCHECKBOX  (4) NURSING HOME/LONGTERM CARE FACILITY___________________________________________________________________________________________________SOURCE OF REFERRAL FORMCHECKBOX   (1) EYE CARE PROVIDER (OPHTHALMOLOGIST, OPTOMETRIST) FORMCHECKBOX   (2) PHYSICIAN/MEDICAL PROVIDER FORMCHECKBOX   (3) STATE VR AGENCY  FORMCHECKBOX   (4) GOVERNMENT OR SOCIAL SERVICE AGENCY FORMCHECKBOX   (5) SENIOR PROGRAM FORMCHECKBOX   (6) FAITH-BASED  ORGANIZATION FORMCHECKBOX   (7) INDEPENDENT LIVING CENTER FORMCHECKBOX   (8) FAMILY MEMBER OR FRIEND FORMCHECKBOX   (9)  SELF-REFERRAL FORMCHECKBOX  (10) VETERANS ADMINISTRATION FORMCHECKBOX  (11) OTHER___________________________________________________________________________________________________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MO 886-4003 (10-08)                                                                                 PAGE 2                                                                                                              OBS-1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 application presumed eligible for Older Blind Services from the State when evidence 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 preferences, 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 in situations where Federal or State laws take precedence over the Rehabilitation Act of 1973.  The 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  a n   a d m i n i s t r a t i v e   r e v i e w .     I   m a y   e x e r c i s e   t h i s   o p t i o n   b y   p u t t i n g   m y   r e q u e s t   i n   w r i t i n g   t o   t h e   D i s t r i c t   S u p e r v i s o r   o f   t h e   l o c a l   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   o f f i c e ,      F O R M T E X T                                                               .     I n   a d d i t i o n ,   M i s s o u r i   P r o t e c t i o n   a      D  F  J    	  	  	  H	  J	  ^	  `	  b	  l	  n	  p	  	  	  巨pWH8                  h8 hl 5CJ OJ QJ aJ h8 hTe CJ OJ QJ aJ  0j    h8 hM)6 CJ OJ QJ UaJ mH nH u +je  h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  %j    h8 hM)6 CJ OJ QJ UaJ h8 h|a/ CJ OJ QJ aJ  h8 h|a/ 5CJ OJ QJ aJ h8 h|a/ 5OJ QJ #jE
h8 h|a/ OJ QJ UVh8 h|a/ OJ QJ  j    h8 h|a/ OJ QJ U    L      	  	  D	  F	  H	  p	  	  	  	  	                                                  r                                                                                                               }  kd  $$If   l             z0 + X                 &                
t  0                                6                          4   4 
l a  yt8    $If   l                	  	  	  	  	  	  	  	  	  	  	  	  	  	  	   
  
  
  
  
  
   
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  ϹޠvgQޠB             h8 hq+, CJ OJ QJ aJ  +j  h8 hk9O CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 h|a/ CJ OJ QJ aJ  h8 h|a/ 5CJ OJ QJ aJ h8 h|a/ OJ QJ  0j    h8 hM)6 CJ OJ QJ UaJ mH nH u +j  h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  %j    h8 hM)6 CJ OJ QJ UaJ h8 hl CJ OJ QJ aJ 	  	  	  	  	  
              t            t            t            t                                                                                                                                                              $If   l               {  kd3  $$If   l             0 e+                  3                
t  0                                6                          4   4 
l a  yt8  
  
  
  
   
  H
  T
  V
  X
  
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  
                                                                                                                                                                                                    $If   l               h  kdr  $$If   l              + ,                
t  0                                6              4   4 
l a  yt8  6
  8
  :
  D
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  |
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  
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  
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  ֽ֮iֽZJ4+j  h8 hk9O CJ OJ QJ UaJ h8 hl 5CJ OJ QJ aJ h8 h|a/ CJ OJ QJ aJ  +js  h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  h8 hq+, 5CJ OJ QJ aJ h8 h|a/ 5CJ OJ QJ aJ h8 hTe CJ OJ QJ aJ  0j    h8 hM)6 CJ OJ QJ UaJ mH nH u %j    h8 hM)6 CJ OJ QJ UaJ +j  h8 hk9O CJ OJ QJ UaJ  
  
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        
  "  $  8  :  <  F  H  J  x  z  |  ~    ŵԖuԖ_PԖ                          h8 hTe CJ OJ QJ aJ  +j6  h8 hk9O CJ OJ QJ UaJ h8 h|a/ OJ QJ  +j  h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  h8 hl 5CJ OJ QJ aJ h8 h|a/ 5CJ OJ QJ aJ h8 hl CJ OJ QJ aJ  %j    h8 hM)6 CJ OJ QJ UaJ 0j    h8 hM)6 CJ OJ QJ UaJ mH nH u
  
    
       "  J  x                          N                                                                                          kdw  $$If   l             \ e!+ 6                                                   
                
t  0                                6                                                  4   4 
l a  yt8    $If   l                x  z  |              0  2  4                                                                                      a                                                     kdn  $$If   l             F \l+                                   ,                
t  0                                6                                      4   4 
l a  yt8    $If   l                                                   .  0  4  ֽ֮q[ֽրP@@                             h8 h,5X 5CJ OJ QJ aJ h8 h|a/ OJ QJ  +j  h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  h8 hl CJ OJ QJ aJ  h8 h|a/ CJ OJ QJ aJ  h8 h|a/ 5CJ OJ QJ aJ h8 hq+, CJ OJ QJ aJ  0j    h8 hM)6 CJ OJ QJ UaJ mH nH u %j    h8 hM)6 CJ OJ QJ UaJ +j  h8 hk9O CJ OJ QJ UaJ  4  6  J  L  N  X  Z  \  t  v  z  |                    뙉yiQiyA                          h8 hl 5CJ OJ QJ aJ .j  h8 hk9O 5CJ OJ QJ UaJ  h8 hq+, 5CJ OJ QJ aJ h8 h|a/ 5CJ OJ QJ aJ h8 h,5X 5CJ OJ QJ aJ h8 hTe 5CJ OJ QJ aJ 3j    h8 hM)6 5CJ OJ QJ UaJ mH nH u.j  h8 hk9O 5CJ OJ QJ UaJ  h8 hM)6 5CJ OJ QJ aJ (j    h8 hM)6 5CJ OJ QJ UaJ 4  \  v  x  z                  >  n  p  r                                                                                                                                                                                                                                                                                                                                                                                                            $If   l                                        ,  .  0  쟏oZJ2Z                          .j+   h8 hk9O 5CJ OJ QJ UaJ  h8 hM)6 5CJ OJ QJ aJ (j    h8 hM)6 5CJ OJ QJ UaJ  h8 hq+, 5CJ OJ QJ aJ h8 h|a/ 5CJ OJ QJ aJ h8 h,5X 5CJ OJ QJ aJ h8 hl CJ OJ QJ aJ  0j    h8 hM)6 CJ OJ QJ UaJ mH nH u +jw  h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  %j    h8 hM)6 CJ OJ QJ UaJ  0  :  <  >  l  n  r  t                    q[B2                h8 hTe 5CJ OJ QJ aJ 0j    h8 hM)6 CJ OJ QJ UaJ mH nH u +j   h8 hk9O CJ OJ QJ UaJ h8 hM)6 CJ OJ QJ aJ  %j    h8 hM)6 CJ OJ QJ UaJ h8 hq+, CJ OJ QJ aJ  h8 h|a/ CJ OJ QJ aJ  h8 h,5X CJ OJ QJ aJ  h8 hq+, 5CJ OJ QJ aJ (j    h8 hM)6 5CJ OJ QJ UaJ  3j    h8 hM)6 5CJ OJ QJ UaJ mH nH u               K            ;            ;            ;            ;            ;                           $If   l                 kd1"  $$If   l             r \X + t                 T                 $	                 	                 @                
t  0                                6                                                              4   4 
l a  yt8                           *  +  ¨v`QB/                         %j    h8 hp CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 hUN CJ OJ QJ aJ  +j#  h8 hN CJ OJ QJ UaJ h8 h!fu CJ OJ QJ aJ  %j    h8 h!fu CJ OJ QJ UaJ h8 hTe 5CJ OJ QJ aJ 3j    h8 hM)6 5CJ OJ QJ UaJ mH nH u(j    h8 hM)6 5CJ OJ QJ UaJ  .j#  h8 hk9O 5CJ OJ QJ UaJ  h8 hM)6 5CJ OJ QJ aJ       F  G  V  W              ,  -                          t                                                                                                                                           {  kd%  $$If   l             0 +                                  
t  0                                6                          4   4 
l a  yt8    $If   l                +  9  :  ;  A  E  G  W  X  f  g  h  j                  ȹu]N8ȹ        +j&  h8 hp CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  .j%  h8 hN 5CJ OJ QJ UaJ  h8 h!fu 5CJ OJ QJ aJ (j    h8 h!fu 5CJ OJ QJ UaJ  h8 hTe 5CJ OJ QJ aJ h8 hUN CJ OJ QJ aJ  h8 hTe CJ OJ QJ aJ  %j    h8 hp CJ OJ QJ UaJ +jt$  h8 hp CJ OJ QJ UaJ h8 hp CJ OJ QJ aJ                             
        !  +  ,  -  .  <  =  >  ĵ}nXnB   +j;)  h8 hp CJ OJ QJ UaJ +j(  h8 hp CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  +j'  h8 hp CJ OJ QJ UaJ h8 hp CJ OJ QJ aJ  %j    h8 hp CJ OJ QJ UaJ h8 hUN CJ OJ QJ aJ  h8 hTe CJ OJ QJ aJ  h8 hT CJ OJ QJ aJ  h8 hUN CJ OJ QJ aJ  h8 h[C CJ OJ QJ aJ >  c  m  n  o  p  ~                                            &  (  *  ııvgQgg        +j+  h8 hp CJ OJ QJ UaJ h8 h[C CJ OJ QJ aJ  +j+  h8 hp CJ OJ QJ UaJ +j[*  h8 hp CJ OJ QJ UaJ h8 hp CJ OJ QJ aJ  %j    h8 hp CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 hTe CJ OJ QJ aJ  h8 hT CJ OJ QJ aJ  h8 hUN CJ OJ QJ aJ -  n  o          &  (  *  h  j                                                                                                                                                                                                         h  kd,  $$If   l              + ,                
t  0                                6              4   4 
l a  yt8    $If   l                *  b  f  h  j  l                      V  X  \    ycTET                                       h8 h CJ OJ QJ aJ  h8 hUN CJ OJ QJ aJ  +j/  h8 hN CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  +jz-  h8 hN CJ OJ QJ UaJ h8 h!fu CJ OJ QJ aJ  %j    h8 h!fu CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 hTe 5CJ OJ QJ aJ h8 hcM 5CJ OJ QJ aJ h8 h[C 5CJ OJ QJ aJ                                         뚋xiSxD5D5            h8 h9* CJ OJ QJ aJ  h8 h`i CJ OJ QJ aJ  +j1  h8 hN CJ OJ QJ UaJ h8 h!fu CJ OJ QJ aJ  %j    h8 h!fu CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 hTe CJ OJ QJ aJ  3j    h8 h<o >*CJ OJ QJ UaJ mH nH u.jp0  h8 hk9O >*CJ OJ QJ UaJ  h8 h<o >*CJ OJ QJ aJ (j    h8 h<o >*CJ OJ QJ UaJ     :  <  >          F  G  g  h                                                                                                                                                                                                       h  kd5  $$If   l              + ,                
t  0                                6              4   4 
l a  yt8    $If   l                              (  *  ,  6  8  :  <  >  r  t    įm^N>N                                   h8 h y 5CJ OJ QJ aJ h8 hTe 5CJ OJ QJ aJ h8 hTe CJ OJ QJ aJ  3j    h8 h<o >*CJ OJ QJ UaJ mH nH u.j3  h8 hk9O >*CJ OJ QJ UaJ  h8 h<o >*CJ OJ QJ aJ (j    h8 h<o >*CJ OJ QJ UaJ  h8 hTe CJ OJ QJ aJ  h8 h`i CJ OJ QJ aJ  h8 h9* CJ OJ QJ aJ  h8 hW CJ OJ QJ aJ                           )  *  +  F  G  H  V  W  X  g  h  i  yjTyj>yj+jI8  h8 hN CJ OJ QJ UaJ +j7  h8 hN CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 hTe CJ OJ QJ aJ  +j5  h8 hN CJ OJ QJ UaJ h8 hW CJ OJ QJ aJ  %j    h8 hW CJ OJ QJ UaJ h8 hcM CJ OJ QJ aJ  h8 hTe 5CJ OJ QJ aJ h8 hK 5CJ OJ QJ aJ h8 hcM 5CJ OJ QJ aJ  i  w  x  y                              2  ]  s  z            ȹȹymyyyyeZJ              h8 hw 5CJ OJ QJ aJ h|a/ hTe OJ QJ  hTe OJ QJ  h5! CJ OJ QJ aJ  h> hTe CJ OJ QJ aJ  hTe CJ OJ QJ aJ  +j9  h8 hN CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 hTe CJ OJ QJ aJ  %j    h8 hW CJ OJ QJ UaJ +j8  h8 hN CJ OJ QJ UaJ h8 hW CJ OJ QJ aJ                       H  I  g  h                                                                                                                                                                                              gdTe h  kdk:  $$If   l              + ,                
t  0                                6              4   4 
l a  yt8    $If   l                                                          G  I  J  X  Y  Z  f  h  v`vJv    +j*@  h8 hN CJ OJ QJ UaJ +j\?  h8 hN CJ OJ QJ UaJ h8 h CJ OJ QJ aJ  +j<  h8 hN CJ OJ QJ UaJ +j:  h8 hN CJ OJ QJ UaJ h8 hW CJ OJ QJ aJ  %j    h8 hW CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 h$ CJ OJ QJ aJ  h8 h(r CJ OJ QJ aJ h  i  w  x  y                          
  %  '  (  6  7  8  ]  _  `  |  츩ݓ츩}쩸g츩\L             h8 h$t^ 5CJ OJ QJ aJ h8 hTe OJ QJ  +jE  h8 hN CJ OJ QJ UaJ +jTC  h8 hN CJ OJ QJ UaJ +j B  h8 hN CJ OJ QJ UaJ h8 hTe CJ OJ QJ aJ  h8 h CJ OJ QJ aJ  +j A  h8 hN CJ OJ QJ UaJ h8 hW CJ OJ QJ aJ  %j    h8 hW CJ OJ QJ UaJ  h          %  '  ^  _  `  }  ~                                                                                                  t            a            a                  $If   gd$t^ l               h  kdE  $$If   l              + (,                
t  0                                6              4   4 
l a  yt8    $If   gd l                  $If   l                |  }                                        ̘̽z̽d̘UF6    h8 h$t^ 5CJ OJ QJ aJ h8 hoj CJ OJ QJ aJ  h8 h;% CJ OJ QJ aJ  +jG  h8 hN CJ OJ QJ UaJ h8 h$t^ CJ OJ QJ aJ  h8 h9* CJ OJ QJ aJ  h8 h(! CJ OJ QJ aJ  +jUF  h8 hN CJ OJ QJ UaJ h8 hj, CJ OJ QJ aJ  %j    h8 hj, CJ OJ QJ UaJ h8 h9* 5CJ OJ QJ aJ h8 hTe 5CJ OJ QJ aJ  ~                E  F                                                                      q            q            q            q            q            q            q            q                $If   gd+sk l               h  kdG  $$If   l              + (,                
t  0                                6              4   4 
l a  yt8    $If   gd$t^ l                                    1  H  I  W  X  Y  Z            ³³iZK;³         h8 h 5CJ OJ QJ aJ h8 h CJ OJ QJ aJ  h8 h(! CJ OJ QJ aJ  +jTI  h8 hN CJ OJ QJ UaJ h8 h+sk CJ OJ QJ aJ  h8 h;% CJ OJ QJ aJ  +jlH  h8 hN CJ OJ QJ UaJ h8 hj, CJ OJ QJ aJ  %j    h8 hj, CJ OJ QJ UaJ h8 hTe 5CJ OJ QJ aJ h8 h+sk 5CJ OJ QJ aJ h8 hTe OJ QJ                       S  T  h  i  w  x  y        Ǹ֩Ǹue֩O@֩                        h8 h4 CJ OJ QJ aJ  +j^K  h8 hN CJ OJ QJ UaJ h8 h4 5CJ OJ QJ aJ h8 h`i CJ OJ QJ aJ  h8 h(r CJ OJ QJ aJ  +jJ  h8 hN CJ OJ QJ UaJ h8 hj, CJ OJ QJ aJ  h8 h+sk CJ OJ QJ aJ  h8 h CJ OJ QJ aJ  %j    h8 hj, CJ OJ QJ UaJ +jJ  h8 hN CJ OJ QJ UaJ      T  g  h              H  I  o  p              *  +  Z  [  x                                                                                                                                                                                                                                                                                                                      $If   gd4 l                  $If   gd+sk l                                          I  J  X  Y  Z  p  q                    ָָָvָ`ָJ    +jQ  h8 hN CJ OJ QJ UaJ +jP  h8 hN CJ OJ QJ UaJ +j>P  h8 hN CJ OJ QJ UaJ +jPO  h8 hN CJ OJ QJ UaJ +jVN  h8 hN CJ OJ QJ UaJ h8 hj, CJ OJ QJ aJ  h8 h4 CJ OJ QJ aJ  %j    h8 hj, CJ OJ QJ UaJ +jL  h8 hN CJ OJ QJ UaJ                      +  ,  :  ;  <  [  \  j  k  l  x    ݢ݌yjTyE                             h8 h(r CJ OJ QJ aJ  +jU  h8 h~ CJ OJ QJ UaJ h8 h~ CJ OJ QJ aJ  %j    h8 h~ CJ OJ QJ UaJ +j<T  h8 hN CJ OJ QJ UaJ +jvS  h8 hN CJ OJ QJ UaJ h8 h4 CJ OJ QJ aJ  +jR  h8 hN CJ OJ QJ UaJ h8 hj, CJ OJ QJ aJ  %j    h8 hj, CJ OJ QJ UaJ  x    t                                                ^            Y            Y            I                                      $If   l                  gdTe h  kdX  $$If   l              + (,                
t  0                                6              4   4 
l a  yt8    $If   gd+sk l                  $If   gd(r l                  $If   gd4 l                  t  u                                ʲk\QB6B                   hTe CJ OJ QJ aJ  h> hTe CJ OJ QJ aJ  h8 hTe OJ QJ  h8 h;% CJ OJ QJ aJ  +jHX  h8 hN CJ OJ QJ UaJ h8 h- CJ OJ QJ aJ  %j    h8 h- CJ OJ QJ UaJ h8 h(r CJ OJ QJ aJ  .jU  h8 hN 5CJ OJ QJ UaJ  h8 hMl 5CJ OJ QJ aJ (j    h8 hMl 5CJ OJ QJ UaJ  h8 h(r 5CJ OJ QJ aJ              4  _  c                !  !  X#  \#  ^#  r#  t#  v#  ³sdNs                                          +jCY  h8 hk9O CJ OJ QJ UaJ h8 hk9O CJ OJ QJ aJ  %j    h8 hk9O CJ OJ QJ UaJ h8 h$0 CJ OJ QJ aJ  h8 h- CJ OJ QJ aJ  h8 h] CJ OJ QJ aJ  h8 h CJ OJ QJ aJ  h8 h OJ QJ  h CJ OJ QJ aJ  hTe CJ OJ QJ aJ  h> hTe CJ OJ QJ aJ  h5! CJ OJ QJ aJ   !  !  }  ~  2~  T~  r~  ~  ~  +  ,  [    6  8                                                                                                                                                                                                                                                                                                                                  $If   l                  $If   gdl l                  dh $If   gd8 l                v#  #  #  #  #   $   |   |  9|  }  }  w~  ~  ~  ~  +  ,  [  \  f  g     
      ŵv`Q                                      h8 h CJ OJ QJ aJ  +jZ  h8 hk9O CJ OJ QJ UaJ h8 hk9O CJ OJ QJ aJ  h8 hl 5CJ OJ QJ aJ h8 hl CJ OJ QJ aJ  Uh8 h] CJ OJ QJ aJ  h8 h] 5CJ OJ QJ aJ h8 h- CJ OJ QJ aJ  %j    h8 hk9O CJ OJ QJ UaJ 0j    h8 hk9O CJ OJ QJ UaJ mH nH u                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                nd Advocacy Services operates a Client Assistance Program which may be of interest and help to me.  The Client Assistance Program provides several services including assistance in pursuing legal, administrative, or other solutions to protect my rights under the Rehabilitation Act of 1973, as amended.  They also provide information about other agencies and programs in Missouri which offer rehabilitation services to persons 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                                                                                                                                                                   F O R M T E X T              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   M O   8 8 6 - 4 0 0 3   ( 1 0 - 0 8 )                                                                                                                                                                                                         $  &  (  2  4  6  :  ^  `  d  f  z  |  ~  쟔t_O7_                               .j(]  h8 hN 5CJ OJ QJ UaJ  h8 h- 5CJ OJ QJ aJ (j    h8 h- 5CJ OJ QJ UaJ  h8 h 5CJ OJ QJ aJ h8 h] 5CJ OJ QJ aJ h8 h OJ QJ  h8 h$0 CJ OJ QJ aJ  0j    h8 hN CJ OJ QJ UaJ mH nH u +j[  h8 hN CJ OJ QJ UaJ h8 hN CJ OJ QJ aJ  %j    h8 hN CJ OJ QJ UaJ  8  :  `  b  d          ڀ                                                                                                                                                                                                                                  $If   l               h  kd\  $$If   l              + (,                
t  0                                6              4   4 
l a  yt8  	~                Ȁ  ʀ  ̀  ր  ؀  ڀ  ܀            *  ЀhXMM>                    h> h] CJ OJ QJ aJ  h8 h OJ QJ  h8 h7 5CJ OJ QJ aJ .j]  h8 hN 5CJ OJ QJ UaJ  h8 h- 5CJ OJ QJ aJ h8 h7 5CJ OJ QJ aJ h8 h 5CJ OJ QJ aJ h8 h] 5CJ OJ QJ aJ h8 h] 5CJ OJ QJ aJ (j    h8 h- 5CJ OJ QJ UaJ  3j    h8 h- 5CJ OJ QJ UaJ mH nH u ڀ  ܀        
                t            t            t            t            t                                                                                                                                             $If   l               {  kd_  $$If   l             0 d+                  X                
t  0                                6                          4   4 
l a  yt8      r  s  t                                      }                                                                                                                                                                                                    gd] {  kd_  $$If   l             0 t"+ "                 H	                
t  0                                6                          4   4 
l a  yt8  *  ,  0  :  R                G  K  q  r  s  t                                                                                                                                                                                                                                                                                                              h|a/ h-q  OJ QJ  hl CJ OJ QJ aJ  Uh5! CJ OJ QJ aJ  h> h] CJ OJ QJ aJ  h] CJ OJ QJ aJ                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             OBS-1                                                                                                                                                                                                                                                                                                                                                                                                            2 1h:pTe / =!@"@#@$@%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                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   K   L   M   N   O   P   Q   n   T   l      X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k      o   p   q   r   s   t   u   v   w   x   y   z   {   |   }   ~         R o o t   E n t r y                                                 	           F            0(V          D a t a                                                         
                                     J   6`      W o r d D o c u m e n t                                                                                     4      O b j e c t P o o l                                                                        `0(            _ 1 1 7 3 5 2 0 1 5 2                                               PRP '    ``             O l e                                                         
                                         7        W P G 2 0                                                                                                W   (       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?_? |??$  ?V?>?R? ? ? ?  8                      `   ?  ?? ?& ??|c < <?~|>     ??  u ?  s 8?? ?  ?    p Ç  >     ? ??up?u0Çp up ? >0 F 0? 0  >aa `Ï?`  ?a  p~ 0?q~  0~ ,?  ~   ???S ?  
  ?A0?v0?  ~ 3   &U3@tEV                                                                                                                                                                                                                                                                                                                O b j I n f o                                                      	                                                  B O l e P a r t                                                
                                                  W P G E x t e n t s                                                                                    
       1 T a b l e                                                                                                    /                                                                                                                                                 8m%ֳ~kxUAɱ&`8_RPX2܍O@\3w|BnOm;4{{[K0ҝ}cO7Sdu-i}yLEtB7oGoES,^gFX>ê#§lN1a[Ōp˅/r=a_L3e>+h)|0||qӝ-6lTгM.1I4_s'/b_HM'`7N5J&Yg_N@i)	<1Vm[=SP.8N?îTzjWwRx!iWFk 8ĚUbRsV<&e
;KsmoA)(^zj9i[/#:42;n0Tty{IaCUPQ͖!?kZ!z,ޟgXw{E'=TE#ҎAЖtx)(nVw[CiwQrtn\!7WVLj!Cw)}6gfcKg0^p FϥSy5;2@Ԛޠ*ޑ<,?!YN=ğ^=V	xKJ~?P,U7W(O<]Ҷe*Qn71
#0S-ȵؿ=6ajco_!O6^\ng7'j6cemg	FQo>jmtkO7tQ0j;vnk{)̨h?wY2,g}.Vûirz;L̽.6=+tzY.s|Zǟd|s313?\ w-    IENDB` $$If     !v h5 X5&#v X#v&:V l z
t  0                                65 X5&yt8 "  D                                                                    T e x t 1           / O   B   S   C l i e n t   N a m e    
 L a s t ,   F i r s t ,   M i d d l e   I n i t i a l   ( C L I E N T   N A M E ,   L A S T ,   F I R S T ,   M I D D L E   I N I T I A L              D                                                                    T e x t 2            O   B   S   C a s e   N u m b e r    C A S E   N U M B E R            $$If     !v h5 53#v #v3:V l 
t  0                                65 53yt8    D                                                                    T e x t 3            S t r e e t   A d d r e s s    S T R E E T   A D D R E S S           { $$If     !v h5 ,#v ,:V l 
t  0                                65 ,yt8    D                                                                    T e x t 4            C i t y    C I T Y              D                                                                    T e x t 5            S t a t e    S T A T E              D                                                                    T e x t 6            Z i p   C o d e    Z I P   C O D E              D                                                                    T e x t 7            C o u n t y   N a m e   a n d   C o u n t y   N u m b e r    C O U N T Y   N A M E   A N D   C O U N T Y   N U M B E R            $$If     !v h5 6555
#v 6#v#v#v
:V l 
t  0                                65 6555
yt8    D                                                                    T e x t 8            C l i e n t   T e l e p h o n e   N u m b e r    T E L E P H O N E   N U M B E R              D                                                                    T e x t 9            S o c i a l   S e c u r i t y   N u m b e r    S O C I A L   S E C U R I T Y   N U M B E R              D                                                                    T e x t 1 0            D a t e   o f   B i r t h    D A T E   O F   B I R T H            $$If     !v h5 55,#v #v#v,:V l 
t  0                                65 55,yt8    D                                                                    T e x t 1 1            R e f e r r a l   D a t e    R E F E R R A L   D A T E              D                                                                    T e x t 1 3            A p p l i c a t i o n   D a t e    A P P L I C A T I O N   D A T E              D                                                                    T e x t 1 2            C a s e   l o a d   N u m b e r    C A S E L O A D   N U M B E R              D                                                                    T e x t 1 4            P r e v i o u s   O   B   S   C a s e    P R E V I O U S   O B S   C A S E           H  D                                                                    T e x t 1 5           > I f   c l i e n t   h a d   a     p r e v i o u s   O   B   S   c a s e   w h a t   w a s   t h e   c l o s u r e   d a t e   + I F   Y E S   T O   P R E V I O U S   C A S E ,   E N T E R   C L O S U R E   D A T E            $$If     !v h5 t5T5$	5	5@#v t#vT#v$	#v	#v@:V l 
t  0                                65 t5T5$	5	5@yt8    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   ( 1 )   F E M A L E              D                                                                   C h e c k 2          F E M A L E    ( 2 )   M A L E            $$If     !v h5 5#v #v:V l 
t  0                                65 5yt8 .  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   F R A C E / E T H N I C I T Y   ( 1 )   H I S P A N I C /   L A T I N O   O F   A N Y   R A C E   O R   H I S P A N I C / L A T I N O   O N L              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   $ ( 2 )   A M E R I C A N   I N D I A N   O R   A L A S K A   N A T I V E              D                                                                   C h e c k 5         ! A m e r i c a n   I n d i a n   o r   A l a s k a n   N a t i v e   	 ( 3 )   A S I A N              D                                                                   C h e c k 6          A s i a n    ( 4 )   B L A C K   O R   A F R I C A N   A M E R I C A N              D                                                                   C h e c k 7         ) H a w a i i a n   N a t i v e   o r   O t h e r   P a c i f i c   I s l a n d e r   - ( 5 )   N A T I V E   H A W A I I A N   O R   O T H E R   P A C I F I C   I S L A N D E R              D                                                                   C h e c k 8          H i s p a n i c   o r   L a t i n o   	 ( 6 )   W H I T E              D                                                                   C h e c k 9         * O T H E R   R A C E / E T H N I C I T Y   N O T   P R E V I O U S L Y   L I S T E D    ( 7 )   T W O   O R   M O R E   R A C E S             D                                                               e    C h e c k 6 2             H ( 8 )     R A C E   A N D   E T H N I C I T Y   U N K N O W N     (   O n l y   i f   c o n s u m e r   r e f u s e s   t o   i d e n t i f y )           { $$If     !v h5 ,#v ,:V l 
t  0                                65 ,yt8   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   B     D E G R E E   O F   V I S U A L   I M P A I R M E N T       ( 1 )   T O T A L L Y   B L I N D   ( L P   O N L Y   O R   N 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   N 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 :                         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    ( 3 )     S E V E R E   V I S U A L   I M P A I R M E N T ,   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 :                   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           { $$If     !v h5 ,#v ,:V l 
t  0                                65 ,yt8   D                                                                   C h e c k 1 3         T M a j o r   C a u s e   o f   V i s u a l   I m p a i r m e n t   A s   r e p o r t e d   b y   t h e   i n d i v i d u a l  
 M a c u l a r   D e g e n e r a t i o n   f   M A J O R   C A U S E   O F   V I S U A L   I M P A I R M E N T S   (   C H E C K   O N L Y   O N E   M A J O R   V I S U A L   I M P A I R M E N T   )   ( 1 )   M A C U L A R   D E G E N E R A T I O N              D                                                                   C h e c k 1 4          D i a b e t i c   R e t i n o p a t h y    D I A B E T I C   R E T I N O P A T H Y              D                                                                   C h e c k 1 5          G l a u c o m a    ( 3 )   G L A U C O M A              D                                                                   C h e c k 1 6         	 C a t a r a c t s    ( 4 )   C A T A R A C T S              D                                                                   C h e c k 1 7         - O t h e r   v i s u a l   i m p a i r m e n t   n o t   p r e v i o u s l y   l i s t e d   	 ( 5 )   O T H E R           { $$If     !v h5 ,#v ,:V l 
t  0                                65 ,yt8   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   M   O T H E R   A G E   R E L A T E D   I M P A I R M E N T S     ( C H E C K   A L L   T H A T   A P P L Y )   ( 1 )   H E A R I N G   I M P A I R M E N T           d  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 )   D I A B E T E S              D                                                                   C h e c k 2 0          C a n c e r   & ( 3 )   C A R D I O V A S C U L A R   D I S E A S E   A N D   S T R O K E S              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   
 ( 4 )   C A N C E R              D                                                                   C h e c k 2 2          D i a b e t e s   M e l l i t i s   4 ( 5 )   B O N E ,   M U S C L E ,   S K I N ,   J O I N T ,   A N D   M O V E M E N T   D I S O R D E R           4  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   - ( 6 )   A L Z H E I M E R ' S   D I S E A S E /   C O G N I T I V E   I M P A I R M E N T             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    ( 7 )     D E P R E S S I O N / M O O D   D I S O R D E R S              D                                                               e    C h e c k 6 3             # ( 8 )     O T H E R   M A J O R   G E R I A T R I C   C O N C E R N S           { $$If     !v h5 (,#v (,:V l 
t  0                                65 (,yt8    D                                                               e                 .   T Y P E S   O F   L I V I N G   A R R A N G E M E N T S   ( 1 )     L I V E S   A L O N E              D                                                               e                 7 ( 2 )     L I V E S   W I T H   O T H E R S   ( F A M I L Y ,   S P O U S E ,   C A R E T A K E R ,   E T C )           { $$If     !v h5 (,#v (,:V l 
t  0                                65 (,yt8    D                                                               e                 @     T Y P E S   O F   R E S I D E N C E   ( 1 )     P R I V A T E   R E S I D E N C E   ( H O U S E   O R   A P A R T M E N T )              D                                                               e                 & ( 2 )   S E N I O R   L I V I N G / R E T I R E M E N T   C O M M U N I T Y              D                                                               e                  ( 3 )   A S S I S T E D   L I V I N G   F A C I L I T Y              D                                                               e                 ' ( 4 )   N U R S I N G   H O M E / L O N G T E R M   C A R E   F A C I L I T Y             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   H S O U R C E   O F   R E F E R R A L     ( 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 )           n  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    ( 2 )   P H Y S I C I A N / M E D I C A L   P R O V I D E R              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    ( 3 )   S T A T E   V R   A G E N C Y              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   ' ( 4 )   G O V E R N M E N T   O R   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    ( 5 )   S E N I O R   P R O G R A M              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    ( 6 )   F A I T H - B A S E D     O R G A N I Z A T I O N              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    ( 7 )   I N D E P E N D E N T   L I V I N G   C E N T E R              D                                                                   C h e c k 5 6          S e n i o r   p r o g r a m    ( 8 )   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 7          R e l i g i o u s   o r g a n i z a t i o n    ( 9 )     S E L F - R E F E R R A L              D                                                                             R e l i g i o u s   o r g a n i z a t i o n    ( 1 0 )   V E T E R A N S   A D M I N I S T R A T I O N              D                                                                             R e l i g i o u s   o r g a n i z a t i o n   
 ( 1 1 )   O T H E R             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           { $$If     !v h5 (,#v (,:V l 
t  0                                65 (,yt8 >  D                                                                    T e x t 2 1           2 E n t e r   d i s t r i c t   s u p e r v i s o r   n a m e   a n d   m a i l i n g   a d d r e s s   2 e n t e r   d i s t r i c t   s u p e r v i s o r   n a m e   a n d   m a i l i n g   a d d r e s s             D                                                                    T e x t 2 2           $ E n t e r   d i s t r i c t   o f f i c e   s t r e e t   a d d r e s s   $ E N T E R   D I S T R I C T   O F F I C E   S T R E E T   A D D R E S S           $  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           { $$If     !v h5 (,#v (,:V l 
t  0                                65 (,yt8    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 f   R S B   r e p r e s e n t a t i v e            $$If     !v h5 5X#v #vX:V l 
t  0                                65 5Xyt8  $$If     !v h5 "5H	#v "#vH	:V l 
t  0                                65 "5H	yt8                                                                                                                                                                                                                                                                                                                                                                                                                                                                            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                                                                                          y                                                                                                                                 
   @     L     X     d     p     x                                           DSS                            OBS 1 fill in template (2).dot        WOJCHYV       2         Microsoft Office Word   @    F#    @    c(@    ?܈@    ?܈                                             ՜. +,0           h      p                                                                       (   Missouri Department of Social Services     0                                                                     Title            
  	           F'   Microsoft Office Word 97-2003 Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                   ^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               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	    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                                   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"/>               	  6
  
    4    0    +    >  *        i    h  |              v#    ~  *  t                          !   #   $   %   '   (   *   +   ,   .   /   1   3   4   6   7   9   :   <   A   C   F      	  
  
  x  4      -      h  ~    x    8  ڀ    t                        "   &   )   -   0   2   5   8   ;   B   D   E       "   $                                 "  ,  8  >  K  W  ]  p  |                        &  ,  =  I  O  c  o  u                         *  :  W  g              -  =  o            5  E  l  |                        *  G  W  h  x              	  	  I	  Y	  h	  x	  	  	  	  
  '
  7
  
  
  
  
      H  X          h  x              I  Y  p                +  ;  [  k  t              [  g  m  o  {                  :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 G 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 FFFFF  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  C h e c k 6 2  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  C h e c k 1 8  C h e c k 1 9  C h e c k 2 0  C h e c k 2 1  C h e c k 2 2  C h e c k 2 3  C h e c k 2 4  C h e c k 6 3  C h e c k 4 9  C h e c k 5 0  C h e c k 5 1  C h e c k 5 2  C h e c k 5 3  C h e c k 5 4  C h e c k 5 5  C h e c k 5 6  C h e c k 5 7  C h e c k 6 0  C h e c k 6 1  T e x t 2 1  T e x t 2 2  T e x t 2 3  T e x t 2 4  T e x t 2 5            ,  K  p          =  c           *  W        -  o      5  l            G  h        	  I	  h	  	  	  '
  h        I  p        t      [  o                                    	   
                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;           #  ?  ^          -  P  v          ;  h        >        F  }          +  X  y        	  Z	  y	  	  
  8
  y        Z                n              S6  0 T6  =  U6  t1 V6  Dj  W6  |/ X6  4/ Y6  j  Z6  \[0 [6  E/ \6  l/ ]6  D/ ^6  $g#  _6  0 `6  dg#  a6  / b6  0 c6  4/ d6  f#             r  r      7  7  Y  Y  i  l  ,  ,                                         	    
                                            z  z      S  S  g  k  q  q  4  4                              	   
                         >      *urn:schemas-microsoft-com:office:smarttags
PostalCode :      *urn:schemas-microsoft-com:office:smarttagsStreet 9      *urn:schemas-microsoft-com:office:smarttagsState 8      *urn:schemas-microsoft-com:office:smarttagsCity ;      *urn:schemas-microsoft-com:office:smarttagsaddress 9      *urn:schemas-microsoft-com:office:smarttagsplace =      *urn:schemas-microsoft-com:office:smarttags	PlaceName =      *urn:schemas-microsoft-com:office:smarttags	PlaceType   P                                                                                                          _  m  .  5  d  k  A  E      e  t          r      #     3  3  3  3  3  3  3  3  3  3                         #  ,  ?  K  ^  p                  -  =  P  c  v                   *  ;  W  h              -  >  o            5  F  l  }                    +  G  X  h  y                  	  	  I	  Z	  h	  y	  	  	  	  
  '
  8
  
  
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