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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-13023 Member / Employer Electronic Funds Transfer for Medicaid Purchase Plan Premiums DMS English 05/2024 PDF No
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS English 07/2008 PDF No
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS English 07/2020 Word No
F-16015S Notice of Approval of Benefits/Positive Change in Benefits, Spanish DMS Spanish 07/2020 Word No
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS English 05/2018 Word No
F-16001AR Notice of Denial of Benefits/Negative Change in Benefits, Arabic DMS Arabic 05/2018 PDF No
F-16001CM Notice of Denial of Benefits/Negative Change in Benefits, Chinese (Simplified) DMS Chinese (Simplified) 05/2018 PDF No
F-16001G Notice of Denial of Benefits/Negative Change in Benefits, German DMS German 05/2018 PDF No
F-16001H Notice of Denial of Benefits/Negative Change in Benefits, Hmong DMS Hmong 05/2018 PDF No
F-16001L Notice of Denial of Benefits/Negative Change in Benefits, Laotian DMS Laotian 05/2018 PDF No
F-16001R Notice of Denial of Benefits/Negative Change in Benefits, Russian DMS Russian 05/2018 PDF No
F-16001SO Notice of Denial of Benefits/Negative Change in Benefits, Somali DMS Somali 05/2018 PDF No
F-16001S Notice of Denial of Benefits/Negative Change in Benefits, Spanish DMS Spanish 05/2018 Word No
F-16028 Notice of FoodShare Overissuance DMS English 07/2023 PDF No
F-16028AR Notice of FoodShare Overissuance, Arabic DMS Arabic 07/2023 PDF No
F-16028CM Notice of FoodShare Overissuance, Chinese (Simplified) DMS Chinese (Simplified) 07/2023 PDF No
F-16028G Notice of FoodShare Overissuance, German DMS German 01/2018 PDF No
F-16028H Notice of FoodShare Overissuance, Hmong DMS Hmong 07/2023 PDF No
F-16028L Notice of FoodShare Overissuance, Laotian DMS Laotian 01/2018 PDF No
F-16028R Notice of FoodShare Overissuance, Russian DMS Russian 07/2023 PDF No
F-16028SO Notice of FoodShare Overissuance, Somali DMS Somali 07/2023 PDF No
F-16028S Notice of FoodShare Overissuance, Spanish DMS Spanish 07/2023 PDF No
F-16014 Notice of Program Violation DMS English 03/2018 PDF No
F-01542 Notification of Required Drug Testing DMS English 06/2023 PDF No
F-01542H Notification of Required Drug Testing, Hmong DMS Hmong 06/2023 PDF No
F-01542S Notification of Required Drug Testing, Spanish DMS Spanish 06/2023 PDF No
F-02577 Proof of In-Kind Hours DMS English 06/2023 PDF No
F-02577H Proof of In-Kind Hours, Hmong DMS Hmong 06/2023 PDF No
F-02577S Proof of In-Kind Hours, Spanish DMS Spanish 06/2023 PDF No
F-16026 Prosecution Diversion Agreement DMS English 05/2018 PDF No
F-16026AR Prosecution Diversion Agreement, Arabic DMS Arabic 05/2018 PDF No
F-16026CM Prosecution Diversion Agreement, Chinese (Simplified) DMS Chinese (Simplified) 05/2018 PDF No
F-16026G Prosecution Diversion Agreement, German DMS German 05/2018 PDF No
F-16026H Prosecution Diversion Agreement, Hmong DMS Hmong 05/2018 PDF No
F-16026L Prosecution Diversion Agreement, Laotian DMS Laotian 05/2018 PDF No
F-16026R Prosecution Diversion Agreement, Russian DMS Russian 05/2018 PDF No
F-16026SO Prosecution Diversion Agreement, Somali DMS Somali 05/2018 PDF No
F-16026S Prosecution Diversion Agreement, Spanish DMS Spanish 05/2018 PDF No
F-00233 Renewal Summary Letter DMS English 08/2019 Word No
F-00233H Renewal Summary Letter (Hmong) DMS Hmong 08/2019 Word No
F-00233S Renewal Summary Letter (Spanish) DMS Spanish 08/2019 Word No
F-02642A Report a Change in Circumstance DMS English 08/2020 Word No
F-02642AH Report a Change in Circumstance, Hmong DMS Hmong 08/2020 Word No
F-02642AS Report a Change in Circumstance, Spanish DMS Spanish 08/2020 Word No
F-02642 Report of a Change in Circumstance to Income Maintenance Agencies DMS English 08/2020 Word No
F-02642H Report of a Change in Circumstance to Income Maintenance Agencies, Hmong DMS Hmong 08/2020 Word No
F-02642S Report of a Change in Circumstance to Income Maintenance Agencies, Spanish DMS Spanish 08/2020 Word No
F-00330 Request for Replacement FoodShare and/or Summer EBT Benefits DMS English 10/2024 PDF No
F-00330AR Request for Replacement FoodShare and/or Summer EBT Benefits, Arabic DMS Arabic 10/2024 PDF No
F-00330CM Request for Replacement FoodShare and/or Summer EBT Benefits, Chinese (Simplified) DMS Chinese (Simplified) 10/2024 PDF No

Glossary

 
Last revised January 24, 2023