MISSOURI DEPARTMENT OF SOCIAL SERVICES	P. O. BOX 88
CHILDREN'S DIVISION	JEFFERSON CITY, MO 65103
APPLICATION FOR VARIANCE - RESIDENTIAL TREATMENT AGENCY FOR CHILDREN AND YOUTH

LEGAL NAME OF AGENCY	TELEPHONE NUMBER
ADDRESS(STREET NUMBER, CITY, COUNTY, ZIP CODE)

Explain

We hereby request a variance of Section 13 CSR 35-71.
This request should be granted for the following reasons:

I certify the information provided with this application to be true:
SIGNATURE OF DIRECTOR OR BOARD CHAIRMAN	DATE
TITLE

DO NOT WRITE BELOW THIS LINE

RESPONSE TO REQUEST FOR VARIANCE

The variance is approved for the period ending:

The variance is approved with the following conditions.

The variance is denied.
SIGNATURE OF RESIDENTIAL PROGRAM UNIT STAFF	DATE
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