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CMS 1763 ; Form Title. Acknowledge Receipt of Termination Request.The completion of this form is needed to document your voluntary request for termination of. Steps 1 and 2 must be completed before continuing to Step 3. The SC must complete every field of the form. I am completing the following transaction with the Missouri Secretary of State's Office. R Reinstatement r Withdrawal or Termination r Merger — Date of Merger. A court has terminated the parental rights of the parent who is ordered to pay support. Complete Committee Name. Complete this form to request recovery of an overpayment in any amount from a closed case.