Self-Evaluation Questionnaire - Missouri Department of Labor - MO... 2025

1. Click ‘Get Form’ to open the Self-Evaluation Questionnaire in our editor.
2. Begin by filling in the decedent's name and Social Security number clearly. Ensure accuracy as this information is crucial for processing your claim.
3. Provide the address of the decedent’s Missouri residence at the time of death, along with the date of death and employer’s details.
4. In section A, answer questions regarding the circumstances of death, including rank, marital status, and whether there are surviving children. Attach any required documents such as a death certificate or police report.
5. Complete claimant information in section B. Specify if you are a surviving spouse or child and provide necessary documentation like marriage or birth certificates.
6. If applicable, fill out section C regarding beneficiary designation and attach relevant forms to support your claim.
7. Finally, review all entries for accuracy before signing and notarizing the last page of the form. Submit it either in person or via mail as instructed.

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