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All Income Maintenance (IM) Forms

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

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

Assigned Number Title Division Language Release Date File Type Available to Order
F-16024S FoodShare Notice of Disqualification, Spanish DMS Spanish 07/2023 PDF No
F-16076 FoodShare Six-Month Report DMS English 10/2023 Word No
F-16076A FoodShare Six-Month Report Instructions DMS English 10/2023 Word No
F-16076AH FoodShare Six-Month Report Instructions, Hmong DMS Hmong 10/2023 Word No
F-16076AS FoodShare Six-Month Report Instructions, Spanish DMS Spanish 10/2023 Word No
F-16076H FoodShare Six-Month Report, Hmong DMS Hmong 10/2023 Word No
F-16076S FoodShare Six-Month Report, Spanish DMS Spanish 10/2023 Word No
F-16066 FoodShare Wisconsin Income Change Report DMS English 10/2023 PDF No
F-16066AR FoodShare Wisconsin Income Change Report, Arabic DMS Arabic 10/2023 PDF No
F-16066BU FoodShare Wisconsin Income Change Report, Burmese DMS Burmese 10/2023 PDF No
F-16066CM FoodShare Wisconsin Income Change Report, Chinese Mandarin DMS Chinese Mandarin 10/2023 PDF No
F-16066G FoodShare Wisconsin Income Change Report, German DMS German 10/2023 PDF No
F-16066H FoodShare Wisconsin Income Change Report, Hmong DMS Hmong 10/2023 PDF No
F-16066L FoodShare Wisconsin Income Change Report, Laotian DMS Laotian 10/2023 PDF No
F-16066R FoodShare Wisconsin Income Change Report, Russian DMS Russian 10/2023 PDF No
F-16066SO FoodShare Wisconsin Income Change Report, Somali DMS Somali 10/2023 PDF No
F-16066S FoodShare Wisconsin Income Change Report, Spanish DMS Spanish 10/2023 PDF No
F-16073 FoodShare Wisconsin Nonfinancial Worksheet DMS English 08/2008 PDF No
F-16030A FoodShare Wisconsin Overpayment Calculator DMS English 10/2023 Excel No
F-16029 FoodShare Wisconsin Repayment Agreement DMS English 07/2008 PDF No
F-16029S FoodShare Wisconsin Repayment Agreement, Spanish DMS Spanish 07/2008 PDF No
F-16033 FoodShare Worksheet DMS English 10/2023 PDF No
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS English 09/2013 PDF No
F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions DMS English 09/2013 PDF No
F-01359 Historical Earnings Verification Request DMS English 02/2022 Word No
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program DMS English 06/2023 PDF No
F-10183 Information Change Report DMS English 05/2017 PDF No
F-10183DA Information Change Report, Dari DMS Dari (Afghan Persian) 05/2017 PDF No
F-10183H Information Change Report, Hmong DMS Hmong 05/2017 PDF No
F-10183PA Information Change Report, Pashto DMS Pashto 05/2017 PDF No
F-10183S Information Change Report, Spanish DMS Spanish 05/2017 PDF No
F-10097 Institutional Medicaid Income Allocation DMS English 04/2024 PDF No
F-10097H Institutional Medicaid Income Allocation, Hmong DMS Hmong 04/2024 PDF No
F-10097S Institutional Medicaid Income Allocation, Spanish DMS Spanish 04/2024 PDF No
F-00107 Instructions, Self-Employment Income Report DMS English 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-16030B Instructions: FoodShare Wisconsin Overpayment Calculator DMS English 01/2018 PDF No
F-10110A Instructions: Medicaid/BadgerCare Plus Eligibility Certification DMS English 01/2018 HTML No
F-00219 Instructions: Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Hmong DMS Hmong 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Spanish DMS Spanish 06/2019 PDF No
F-22637 Interagency Notification -Termination of Community Waiver Participation DMS English 03/2017 PDF No
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS English 07/2008 PDF No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-10112A Medicaid - Disability Application Addendum DMS English 11/2020 PDF No

Glossary

 
Last revised January 24, 2023