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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
FoodShare Forms by Form Type

Last Revised: April 24, 2009

This list contains all FoodShare program forms that are available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). Forms marked as "PDF- Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Type Form Title Form Number Revised Date Language
Paper Local Agency Customer Feedback - Spanish F-16104S 1/1/2008 Spanish
pdf Administrative Disqualification Hearing Notice F-16038 7/1/2008 English
pdf Affidavit of Lost Income or Disaster Related Costs F-16106 7/1/2008 English
pdf Affidavit of Lost Income or Disaster-Related Costs - Spanish F-16106S 7/1/2008 Spanish
pdf Affidavit of Return or Exchange of Food Coupons F-09002 12/1/1997 English
pdf BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 7/1/2008 English
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits F-16004 7/1/2008 English
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - - Hmong F-16004H 7/1/2008 Hmong
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Russian F-16004R 7/1/2008 Russian
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish F-16004S 7/1/2008 Spanish
pdf Disaster FoodShare Notice F-16105 7/1/2008 English
pdf Disaster FoodShare Wisconsin Assistance Application F-16060 7/1/2008 English
pdf Disaster FoodShare Wisconsin Assistance Application - Spanish F-16060S 7/1/2008 Spanish
pdf Disqualification Consent Agreement F-16025 7/1/2008 English
pdf Disqualification Consent Agreement - Spanish F-16025S 7/1/2008 Spanish
pdf FoodShare and/or Child Care Six Month Report F-16076 7/1/2008 English
pdf FoodShare and/or Child Care Six Month Report - Spanish F-16076S 7/1/2008 Spanish
PDF FoodShare and/or Child Care Six Month Report Form Instructions F-16076A 7/1/2008 English
PDF FoodShare and/or Child Care Six Month Report Form Instructions - Spanish F-16076AS 7/1/2008 Spanish
PDF FoodShare Employment and Training (FSET) Participation Agreement F-00136 7/1/2009 English
pdf FoodShare Employment and Training (FSET) Participation Agreement - Hmong F-00136H 7/1/2009 Hmong
pdf FoodShare Employment and Training (FSET) Participation Agreement - Spanish F-00136S 7/1/2009 Spanish
pdf FoodShare Wisconsin Application / Registration F-16019B 10/1/2008 English
pdf FoodShare Wisconsin Application / Registration - Hmong F-16019BH 7/1/2008 Hmong
pdf FoodShare Wisconsin Application / Registration - Spanish F-16019BS 10/1/2008 Spanish
pdf FoodShare Wisconsin Change Report F-16006 8/1/2008 English
pdf FoodShare Wisconsin Change Report - Hmong F-16006H 7/1/2008 Hmong
pdf FoodShare Wisconsin Change Report - Russian F-16006R 7/1/2008 Russian
pdf FoodShare Wisconsin Change Report - Spanish F-16006S 7/1/2008 Spanish
pdf FoodShare Wisconsin Income Change Report F-16066 10/1/2008 English
pdf FoodShare Wisconsin Income Change Report - Hmong F-16066H 10/1/2008 Hmong
pdf FoodShare Wisconsin Income Change Report - Hmong F-16066R 10/1/2008 Russian
pdf FoodShare Wisconsin Income Change Report - Spanish F-16066S 10/1/2008 Spanish
PDF FoodShare Wisconsin Nonfinancial Worksheet F-16073 8/1/2008 English
pdf FoodShare Wisconsin Over Issuance Worksheet F-16030 10/1/2008 English
pdf FoodShare Wisconsin Registration / Important Information F-16019A 10/1/2008 English
pdf FoodShare Wisconsin Registration Important Information - Hmong F-16019AH 7/1/2008 Hmong
pdf FoodShare Wisconsin Registration Important Information - Russian F-16019AR 12/1/2004 Russian
pdf FoodShare Wisconsin Registration Important Information - Spanish F-16019AS 10/1/2008 Spanish
pdf FoodShare Wisconsin Repayment Agreement F-16029 7/1/2008 English
pdf FoodShare Wisconsin Repayment Agreement - Spanish F-16029S 7/1/2008 Spanish
pdf FoodShare Wisconsin Worksheet F-16033 10/1/2008 English
PDF ForwardHealth Enrollment and Benefits Handbook - Spanish P-00079S 6/1/2009 Spanish
pdf Income Maintenance Quality Assurance (IMQA) Web Request F-16083 7/1/2008 English
PDF Local Agency Customer Feedback F-16104 8/1/2007 English
pdf Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 7/1/2008 English
pdf Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong F-10126H 7/1/2008 Hmong
pdf Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish F-10126S 7/1/2008 Spanish
PDF MilES Key Contacts P-00087 6/1/2009 English
pdf Negative Notice F-16001 7/1/2008 English
pdf Negative Notice - Spanish F-16001S 4/1/2006 Spanish
pdf Notice of Disqualification F-16024 7/1/2008 English
pdf Notice of Disqualification - Spanish F-16024S 7/1/2008 Spanish
pdf Notice of FoodShare Over issuance F-16028 7/1/2008 English
pdf Notice of FoodShare Overissuance - Spanish F-16028S 7/1/2008 Spanish
pdf Notice of Program Violation F-16014 7/1/2008 English
pdf Positive Notice F-16015 7/1/2008 English
pdf Positive Notice - Spanish F-16015S 4/1/2006 Spanish
pdf Prosecution Diversion Agreement F-16026 7/1/2008 English
pdf Quality Assurance (QA) Sample Check List F-16011 7/1/2008 English
pdf Quest Card and PIN Responsibility Statement F-16007 7/1/2008 English
pdf Quest Card and Pin Responsibility Statement - Hmong F-16007H 7/1/2008 Hmong
pdf Quest Card and Pin Responsibility Statement - Russian F-16007R 7/1/2008 English
pdf Quest Card and Pin Responsibility Statement - Spanish F-16007S 7/1/2008 English
pdf Self-Employment Income Report F-00107 8/1/2009 English
pdf Self-Employment Income Report - Hmong F-00107H 8/1/2009 Hmong
pdf Self-Employment Income Report - Spanish F-00107S 8/1/2009 Spanish
pdf Self-Employment Income Worksheet - Corporation F-16034 5/1/2009 English
pdf Self-Employment Income Worksheet - Partnership F-16036 5/1/2009 English
pdf Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 5/1/2009 English
pdf Self-Employment Income Worksheet - Subchapter S Corporation F-16035 5/1/2009 English
pdf Social Security Number Referral F-16022 7/1/2008 English
pdf Striker Evaluation F-16023 7/1/2008 English
pdf Waiver of Administrative Disqualification Hearing F-16039 7/1/2008 English
pdf Waiver of Administrative Disqualification Hearing - Spanish F-16039S 7/1/2008 Spanish
pdf Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 7/1/2008 English
pdf Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish F-10140S 7/1/2008 Spanish
PDF Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin F-10150 7/1/2008 English
PDF Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish F-10150S 5/1/2007 Spanish
word Employment Verification of Earnings F-10146 7/1/2008 English
word Life Insurance Inquiry F-10144 7/1/2008 English
word Summary of Information Form Letter F-00098 6/1/2009 English