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All Income Maintenance (IM) Forms and Worksheets

Below is a list of all Income Maintenance (IM) forms and worksheets.

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned number Title Release date File type Language Available to order
F-16104H Customer Experience Survey, Hmong 12/2025 PDF Hmong No
F-00332 Medicaid Purchase Plan Premium Information / Payment 10/2025 PDF English No
F-00332S Medicaid Purchase Plan Premium Information / Payment, Spanish 10/2025 PDF Spanish No
F-01318 Medicaid Purchase Plan (MAPP) Medicaid and Remedial Expenses (MRE) Worksheet 10/2025 PDF English No
F-01317 Medicaid Purchase Plan (MAPP) Impairment Related Work Expense (IRWE) Worksheet 10/2025 PDF English No
F-16066BU FoodShare Wisconsin Income Change Report, Burmese 10/2025 PDF Burmese No
F-16066AR FoodShare Wisconsin Income Change Report, Arabic 10/2025 PDF Arabic No
F-16066 FoodShare Wisconsin Income Change Report 10/2025 PDF English No
F-16066G FoodShare Wisconsin Income Change Report, German 10/2025 PDF German No
F-16066H FoodShare Wisconsin Income Change Report, Hmong 10/2025 PDF Hmong No
F-16066L FoodShare Wisconsin Income Change Report, Laotian 10/2025 PDF Lao No
F-16066CM FoodShare Wisconsin Income Change Report, Chinese (Simplified) 10/2025 PDF Chinese (Simplified) No
F-16066S FoodShare Wisconsin Income Change Report, Spanish 10/2025 PDF Spanish No
F-16066R FoodShare Wisconsin Income Change Report, Russian 10/2025 PDF Russian No
F-16066SO FoodShare Wisconsin Income Change Report, Somali 10/2025 PDF Somali No
F-10076A SeniorCare Application Instructions 10/2025 PDF English Yes
F-10076AH SeniorCare Application Instructions, Hmong 10/2025 PDF Hmong No
F-10076AS SeniorCare Application Instructions, Spanish 10/2025 PDF Spanish No
F-10076AL SeniorCare Application Instructions, Laotian 10/2025 PDF Lao No
F-16030A FoodShare Wisconsin Overpayment Calculator 10/2025 Excel English No
F-13023 Member/Employer Electronic Funds Transfer for Medicaid Purchase Plan Premiums 03/2025 PDF English No
N/A Telephonic Signature Prompts 1-17 Hmong 12/2024 PDF Hmong No
N/A Telephonic Signature Prompts 1-17 Spanish 12/2024 PDF Spanish No
F-00330AR Request for Replacement FoodShare and/or Summer EBT Benefits, Arabic 10/2024 PDF Arabic No
F-00330G Request for Replacement FoodShare and/or Summer EBT Benefits, German 10/2024 PDF German No

Glossary

 
Last revised February 20, 2026