Authorized Representative Designation for FSD Benefits (SNAP, Temporary Assistance, and MO HealthNet) Instructions
This form contains 70 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agreement and Signature | ||
| I agree | Checkbox |
Check this box if you agree to submit the authorization electronically and understand that an electronic signature has the same legal effect as a written signature.
|
| Authorized Representative's Signature | Text |
Provide the authorized representative's signature.
|
| Date of Signature | Date |
Enter the date the signature was provided.
|
| Authorized Representative Name or Organization | ||
| Authorized Representative First Name | Text |
Enter the authorized representative's first (given) name whom you are appointing to act on your behalf.
|
| Authorized Representative Middle Name | Text |
Enter the authorized representative's middle name or initial, or leave blank if none.
|
| Authorized Representative Last Name | Text |
Enter the authorized representative's last (family) name or surname.
|
| Authorized Representative Name Suffix | Text |
Enter the authorized representative's name suffix (for example Jr., Sr., III) if applicable, otherwise leave blank.
|
| Authorized Representative Organization or Facility Name | Text |
If the authorized representative is an organization or facility, enter its full legal or business name here; if you listed an individual above, leave this field blank.
|
| General | ||
| SAVE | Button | |
| Button | ||
| RESET | Button | |
| I agree checkbox | ||
| I agree | Checkbox |
Check this box to confirm you agree to submit the form electronically and consent to the Authorization and representation terms described in Section 3.
|
| Mailing Address (PO Box/Street, Apt, City, State, Zip) | ||
| PO Box or Street Address | Text |
Enter the mailing street address or PO Box for this mailing address, including street number and name.
|
| Apartment, Suite, or Trailer Number | Text |
Enter the apartment, suite, unit, or trailer number associated with the mailing address (leave blank if none).
|
| City | Text |
Enter the city or town for the mailing address.
|
| State | Text |
Enter the state for the mailing address (use the two-letter abbreviation or full state name).
|
| ZIP / Postal Code | Text |
Enter the ZIP or postal code for the mailing address, including ZIP+4 digits if applicable.
|
| MHN Authorization Checkboxes | ||
| Help me/us apply for MO HealthNet coverage | Checkbox |
Check this box if you want the authorized person or organization to help you apply for MO HealthNet coverage on your behalf. Fill only if 'Sign and submit an MHN application on my behalf' is 'No'.
|
| Act on my behalf for MO HealthNet (renewals & reporting) | Checkbox |
Check this box if you want the authorized person or organization to act on your behalf for MO HealthNet, including handling annual renewals and reporting changes. Fill only if 'Sign and submit an MHN application on my behalf' is 'No'.
|
| Access FSD account online communications | Checkbox |
Check this box if you want the authorized person or organization to access your FSD account online communications. Fill only if 'Sign and submit an MHN application on my behalf' is 'No'.
|
| Access FSD account online communications after I die | Checkbox |
Check this box if you want the authorized person or organization to continue accessing your FSD account online communications after your death. Fill only if 'Sign and submit an MHN application on my behalf' is 'No'.
|
| Sign and submit an MHN application on my behalf | Checkbox |
Check this box if you authorize the person or organization to sign and submit an MHN application for you (this authorization ends after submission and does not grant other authority or access to protected health information).
|
| Organization or Facility Contact Information | ||
| Organization or Facility PO Box or Street Address | Text |
Enter the PO Box or street address for the organization or facility.
|
| Organization or Facility Apartment, Suite, or Trailer Number | Text |
Enter the apartment, suite, or trailer number for the organization or facility.
|
| Organization or Facility City | Text |
Enter the city for the organization or facility.
|
| Organization or Facility State | Text |
Enter the state for the organization or facility.
|
| Organization or Facility Zip Code | Text |
Enter the zip code for the organization or facility.
|
| Organization or Facility Email Address | Text |
Enter the email address for the organization or facility.
|
| Organization or Facility Phone Number | Text |
Enter the phone number for the organization or facility.
|
| Physical Address (Street, Apt, City, State, Zip) | ||
| Street Address | Text |
Enter the physical street address of your residence, including house number and street name (do not include city, state, or ZIP).
|
| Apartment, Suite, or Trailer Number | Text |
Enter the apartment, suite, unit, or trailer number associated with the physical address, if applicable; leave blank if none.
|
| City | Text |
Enter the city where your physical address is located.
|
| State | Text |
Enter the state for your physical address (two-letter abbreviation or full state name).
|
| ZIP Code | Text |
Enter the ZIP or postal code for your physical address.
|
| Primary Applicant Personal Information | ||
| First name | Text |
Enter your legal first (given) name as it appears on official documents.
|
| Middle name | Text |
Enter your middle name or middle initial, or leave blank if you have none.
|
| Last name | Text |
Enter your legal last (family) name as it appears on official documents.
|
| Name suffix | Text |
Enter any suffix for your name (for example Jr., Sr., III) or leave blank if none.
|
| Date of birth | Date |
Enter the applicant's date of birth.
|
| Social Security Number (optional) | Text |
Enter your Social Security Number (SSN) if you choose to provide it; this field is optional.
|
| Department Client Number (DCN) | Text |
Enter your Department Client Number (DCN) if known, or leave blank if you do not have one.
|
| Email address | Text |
Enter your primary email address for contact regarding this application.
|
| Phone number | Text |
Enter your primary phone number, including country or area code as needed for contact.
|
| Representative's Contact Information | ||
| Representative's Street Address | Text |
Provide the representative's PO Box or street address.
|
| Representative's Apartment/Suite/Trailer Number | Text |
Enter the representative's apartment, suite, or trailer number.
|
| Representative's City | Text |
Enter the city where the representative resides.
|
| Representative's State | Text |
Enter the state where the representative resides.
|
| Representative's Zip Code | Text |
Provide the representative's postal zip code.
|
| Representative's Email Address | Text |
Enter the representative's email address.
|
| Representative's Phone Number | Text |
Provide the representative's phone number.
|
| SNAP Authorization Checkboxes | ||
| Help me/us apply for SNAP benefits, including Mid-certification reviews, report changes, and receive notices | Checkbox |
Check this box to authorize the person or organization to help you apply for SNAP benefits and to handle mid-certification reviews, report changes, and receive notices on your behalf.
|
| Access my benefits and receive an EBT card | Checkbox |
Check this box to authorize the person or organization to access your SNAP benefits and to receive an EBT card on your behalf.
|
| Access FSD account online communications | Checkbox |
Check this box to authorize the person or organization to access and view your FSD account online communications.
|
| Access FSD account online communications after I die | Checkbox |
Check this box to authorize the person or organization to access your FSD account online communications after your death.
|
| Spouse (or second parent) signature and date | ||
| Spouse (or second parent) signature | Text |
Enter the spouse's or second parent's signature or printed name to indicate their agreement and authorization on this form.
|
| Spouse (or second parent) signature date | Date |
Enter the date when the spouse or second parent signed this form. Fill only if 'Spouse (or second parent) signature' is filled.
|
| Spouse or Second Parent Personal Information | ||
| Spouse or Second Parent — First Name | Text |
Enter the spouse or second parent's given (first) name as it appears on legal documents.
|
| Spouse or Second Parent — Middle Name | Text |
Enter the spouse or second parent's middle name or initial; leave blank if none.
|
| Spouse or Second Parent — Last Name | Text |
Enter the spouse or second parent's family (last) name or surname as it appears on legal documents.
|
| Spouse or Second Parent — Suffix | Text |
Enter the spouse or second parent's name suffix (for example Jr., Sr., III); leave blank if none.
|
| Spouse or Second Parent — Date of Birth | Date |
Enter the spouse or second parent's date of birth.
|
| Spouse or Second Parent — Social Security Number (optional) | Text |
Enter the spouse or second parent's Social Security Number; this field is optional, so leave it blank if you do not wish to provide it.
|
| Spouse or Second Parent — DCN (if known) | Text |
Enter the spouse or second parent's Department Client Number (DCN) if known; leave blank if unknown.
|
| Spouse or Second Parent — Email Address | Text |
Enter the spouse or second parent's email address for contact.
|
| Spouse or Second Parent — Phone Number | Text |
Enter the spouse or second parent's primary phone number, including area or country code if applicable.
|
| TA Authorization Checkboxes | ||
| Help me/us apply for TA benefits (includes acting on my/our behalf) | Checkbox |
Check this box when you want to authorize the person or organization to help apply for TA benefits and to act on your behalf for TA matters (including annual reviews, reporting changes, and receiving notices).
|
| Access FSD account online communications | Checkbox |
Check this box when you want to authorize the person or organization to access your FSD account online communications while you are alive.
|
| Access FSD account online communications after I die | Checkbox |
Check this box when you want to authorize the person or organization to access your FSD account online communications after your death.
|
| Your signature and date | ||
| Your signature | Text |
Enter the applicant's handwritten or typed signature to confirm agreement and authorization for the representative. Fill only if 'I agree' is 'Yes'.
|
| Date signed | Date |
Enter the date when the applicant signed this authorization. Fill only if 'Your signature' is filled.
|