MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION MISSOURI TITLE IV-A EMERGENCY ASSISTANCE SERVICES REQUEST
I. EMERGENCY ASSISTANCE SERVICES REQUEST
I request Emergency Assistance from the Children’s Division because I do not have adequate resources immediately available to pay for services for myself or my family.
PARENT/GUARDIAN OR REPRESENTATIVE	DATE	PARENT/GUARDIAN OR REPRESENTATIVE	DATE
AGENCY REPRESENTATIVE (ON BEHALF OF A CHILD IN ALTERNATIVE CARE)	DATE
II. EMERGENCY ASSISTANCE SERVICES ELIGIBILITY
FAMILY MEMBERS (NAMES)	RELATIONSHIP TO CHILD	DCN (IF POSSIBLE) SSN (IF NO DCN AVAILABLE)
COMPLETE THE FOLLWING (CHECK APPROPRIATE BOX)
YES NO
An emergency exists because of child abuse/neglect or “at risk” of child abuse/neglect and this emergency did not arise because an adult family member refused (without good cause) employment or training; or
An emergency exists because this child(ren) is at risk of requiring placement outside the home or in a more restrictive setting due to the inability of the parents or other custodians to provide necessary care of service unaided.
2. This application for Emergency Assistance Services was made by a parent, legal guardian or specified relative of a child under age 21, or by an Agency Representative on behalf of a child under age 21, who is in the legal custody of the state.
3. This child or family member receives AFDC, SSI, Food Stamps, Medicaid, or does not have sufficient resources immediately available to pay for Emergency Assistance Services.
This child has lived with a parent or specified relative within the last six months.
After completing the initial assessment of this family or child, my judgment is that this family or child meet the requirements stated above and is eligible for Emergency Assistance Services, (Any “No” answer means the family is ineligible.
6. Emergency Assistance Services are authorized for a period not to exceed 365 days from the Service Authorization Start Date.
SERVICE AUTHORIZATION START DATE	AUTHORIZED AGENT OF THE STATE	DATE
PARENT/GUARDIAN OR REPRESENTATIVE SIGNATURE	DATE