MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION VENDOR LICENSURE/Approval RESOURCE REPORT for UN, MM, and TL Vendors
1. Action	2. Vendor Number (DVN)	3. Vendor Type	4.Worker:	5. Proof of Tax ID: Yes No
Open Update Close	MM UN TL
SECTION A - DEPARTMENT VENDOR INFORMATION
6. Vendor Name (Last Parent’ #1 Name “and” Parent #2’s Name or Business Name)	7. Telephone Number	8. Minority Status	9. Taxpayer ID No.
10. Address Line 1	11. Address Line 2	12. City	13. State	14. Zip Code
SECTION B - LICENSURE/APPROVAL INFORMATION	SECTION C - AGE/SEX ACCOMMODATION ( not required for UN Vendors)
15. Begin Date (mm\dd\yyyy)	16. End/Close Date (mm\dd\yyyy)	17. Payee DVN	18. Age Range	From From	To To	Sex
Sex
SECTION D - WORKER INFORMATION	Signature:
19. Worker ID Number	20. Worker County	21. Private Agency Code Caseload	Date Form Completed:
Supervisor’s Initials:

Instructions: The SS-60 is used to track application information for Medical/Mental Facility Vendors, MM, and Unclassified Vendors, UN.

Check appropriate box, Open the vendor, Change information, or Close the vendor

Enter Department Vendor Number

Check appropriate vendor type:

MM, Medical/Mental Facility. Opened only by Central Office Interdepartmental Placement Unit

UN, Unclassified Vendors. Opened only by FACES Payment Unit

TL, Transitional Living Group Home or Scattered Site. Opened only by Central Office Older Youth PDS.

Enter worker name completing the form

Check appropriate box for Proof of Tax ID

Section A

Enter name using no commas.

Individual: Last name first, First name, Middle initial; Jones Mary W

Married Couple: Last name, Parent #1’s first name, “and”, Parent #2’s first name; e.g., Brown John and Susan

If different last names: Brown John and Winter Susan

Facility or Company: Business name; e.g., JC Penny Co or Three Amigos Hospital

Enter Telephone Number including area code

Enter Minority Status. A minority owned business is one in which fifty-one (51) percent or more of the ownership is Black, Hispanic, American Indian/ Alaskan, or Asian/ Pacific Islander. This is a mandatory field.

White	4- American Indian/Alaskan Native	U- Unable to Determine

Black	5- Asian/Pacific Islander

Enter Taxpayer Identification Number. Updates to this field may only be completed by FACES Payment Unit.

Enter Address Line 1

Enter Address Line 2 only if there is a Post Office Box in addition to the mailing address in Line 1

Enter City

Enter State with a two letter abbreviation

Enter Zip Code

Section B

Enter Begin Date, month, day and year that the vendor is to become effective

Enter End Date, month, day and year that the vendor is to expire

Enter Payee DVN

Section C (MM vendors only)

Enter Age Range and Sex. Age Range is from 0 to 21. If either sex is accepted, enter B for both

Section D

Enter Worker ID

Enter Worker County

Enter Private Agency Code Case Load

Signatures

Worker completing the form

Date Form Completed, month, day, and year

Supervisor’s Initials