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Eligibility Management (Income Maintenance) Home >> IM Forms

FoodShare Forms by Form Type

Last Revised: March 26, 2014

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 FoodShare Wisconsin Application / Registration (PDF, 657 KB) F-16019B 4/1/2014 English
Paper FoodShare Wisconsin Change Report (PDF, 250 KB) F-16006 6/1/2013 English
Paper FoodShare Wisconsin Income Change Report (PDF, 171 KB) F-16066 10/1/2013 English
Paper FoodShare Wisconsin Registration / Important Information (PDF, 170 KB) F-16019A 4/1/2014 English
Paper Local Agency Customer Feedback (PDF, 129 KB) F-16104 8/1/2014 English
Paper Local Agency Customer Feedback - Spanish (PDF, 29 KB) F-16104S 8/1/2014 Spanish
PDF Administrative Disqualification Hearing Notice (PDF, 101 KB) F-16038 2/1/2014 English
PDF Affidavit of Return or Exchange of Food Coupons (PDF, 615 KB) F-19002 12/1/1997 English
PDF BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) F-10138 7/1/2008 English
PDF Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) F-00628 7/1/2012 English
PDF Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (PDF, 32 KB) F-16004 7/1/2008 English
PDF Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong (PDF, 31 KB) F-16004H 7/1/2008 Hmong
PDF Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish (PDF, 33 KB) F-16004S 7/1/2008 Spanish
PDF Disaster FoodShare Wisconsin Assistance Application (PDF, 67 KB) F-16060 2/1/2012 English
PDF Disaster FoodShare Wisconsin Assistance Application - Spanish (PDF, 75 KB) F-16060S 2/1/2012 Spanish
PDF Disqualification Consent Agreement (PDF, 71 KB) F-16025 2/1/2014 English
PDF Disqualification Consent Agreement - Spanish (PDF, 72 KB) F-16025S 2/1/2014 Spanish
PDF FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) F-00136 2/1/2012 English
PDF FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 42 KB) F-00136H 2/1/2012 Hmong
PDF FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 41 KB) F-00136S 2/1/2012 Spanish
PDF FoodShare Wisconsin Application / Registration - Hmong (PDF, 712 KB) F-16019BH 4/1/2014 Hmong
PDF FoodShare Wisconsin Application / Registration - Spanish (PDF, 677 KB) F-16019BS 4/1/2014 Spanish
PDF FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) F-16006H 6/1/2013 Hmong
PDF FoodShare Wisconsin Change Report - Spanish (PDF, 133 KB) F-16006S 6/1/2013 Spanish
PDF FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) F-16066H 10/1/2013 Hmong
PDF FoodShare Wisconsin Income Change Report - Spanish (PDF, 87 KB) F-16066S 10/1/2013 Spanish
PDF FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) F-16073 8/1/2008 English
PDF FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 238 KB) F-16019AH 4/1/2014 Hmong
PDF FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 299 KB) F-16019AS 4/1/2014 Spanish
PDF FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) F-16029 7/1/2008 English
PDF FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) F-16029S 7/1/2008 Spanish
PDF FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) F-16030 7/1/2011 English
PDF FoodShare Worksheet (PDF, 45 KB) F-16033 7/1/2011 English
PDF Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 8/1/2011 English
PDF Local Agency Customer Feedback (Hmong) (PDF, 55 KB) F-16104H 8/1/2014 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 2/1/2013 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H 2/1/2013 Hmong
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S 2/1/2013 Spanish
PDF Negative Notice (PDF, 154 KB) F-16001 7/1/2008 English
PDF Negative Notice - Spanish (PDF, 74 KB) F-16001S 7/1/2008 Spanish
PDF Notice of Disqualification (PDF, 110 KB) F-16024 2/1/2014 English
PDF Notice of Disqualification - Spanish (PDF, 73 KB) F-16024S 2/1/2014 Spanish
PDF Notice of FoodShare Over issuance (PDF, 288 KB) F-16028 7/1/2008 English
PDF Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) F-16028S 7/1/2008 Spanish
PDF Notice of Program Violation (PDF, 43 KB) F-16014 7/1/2008 English
PDF Positive Notice (PDF, 134 KB) F-16015 7/1/2008 English
PDF Positive Notice - Spanish (PDF, 46 KB) F-16015S 7/1/2008 Spanish
PDF Prosecution Diversion Agreement (PDF, 251 KB) F-16026 7/1/2008 English
PDF Quality Assurance (QA) Sample Check List (PDF, 226 KB) F-16011 7/1/2008 English
PDF Request for Replacement FoodShare Benefits (PDF, 28 KB) F-00330 6/1/2013 English
PDF Self-Employment Income Report (PDF, 91 KB) F-00107 5/1/2013 English
PDF Self-Employment Income Report (Worksheet) (PDF, 32 KB) F-00107W 5/1/2010 English
PDF Self-Employment Income Report - Farmer (PDF, 74 KB) F-00219 6/1/2013 English
PDF Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) F-00219W 5/1/2010 English
PDF Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) F-00219H 6/1/2013 Hmong
PDF Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S 6/1/2013 Spanish
PDF Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H 4/1/2013 Hmong
PDF Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S 4/1/2013 Spanish
PDF Self-Employment Income Worksheet - Corporation (PDF, 25 KB) F-16034 2/1/2014 English
PDF Self-Employment Income Worksheet - Partnership (PDF, 27 KB) F-16036 2/1/2014 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) F-16037 2/1/2014 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) F-16037A 6/1/2014 English
PDF Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) F-16035 2/1/2014 English
PDF Social Security Number Referral (PDF, 61 KB) F-16022 7/1/2008 English
PDF Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H 7/1/2008 Hmong
PDF Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S 7/1/2008 Spanish
PDF Striker Evaluation (PDF, 395 KB) F-16023 7/1/2008 English
PDF Summary of Information Letter (PDF, 224 KB) F-00098 6/1/2009 English
PDF Waiver of Administrative Disqualification Hearing (PDF, 141 KB) F-16039 2/1/2014 English
PDF Waiver of Administrative Disqualification Hearing - Spanish (PDF, 143 KB) F-16039S 2/1/2014 Spanish
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) F-10140 10/1/2012 English
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) F-10140S 10/1/2012 Spanish
PDF Your Rights and Responsibilities for FoodShare (PDF, 81 KB) F-10150B 9/1/2013 English
PDF Your Rights and Responsibilities for FoodShare - Spanish (PDF, 60 KB) F-10150BS 9/1/2013 English
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) F-10150S 9/1/2013 Spanish
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 9/1/2013 English
Word Consortium Response to the State IM Second Party Review Finding F-00628 7/1/2012 English
Word Employment Verification of Earnings F-10146 9/1/2014 English
Word FoodShare and/or Child Care Six Month Report F-16076 6/1/2014 English
Word FoodShare and/or Child Care Six Month Report Instructions - Spanish F-16076AS 6/1/2014 Spanish
Word FoodShare and/or Child Care Six Month Report (Hmong) F-16076H 1/1/2012 Hmong
Word FoodShare and/or Child Care Six Month Report - Spanish F-16076S 6/1/2014 Spanish
Word FoodShare and/or Child Care Six Month Report Form Instructions F-16076A 6/1/2014 English
Word FoodShare and/or Child Care Six Month Report Form Instructions - Hmong F-16076AH 1/1/2012 Hmong
Word FoodShare Employment and Training - Discuss Participant Appointment Letter F-01256 6/1/2014 English
Word FoodShare Employment and Training - Employment Plan (EP) Appointment Letter F-01254 6/1/2014 English
Word FoodShare Employment and Training - Final Notice Appointment Letter F-01253 6/1/2014 English
Word FoodShare Employment and Training - Initial Appointment Letter F-01252 6/1/2014 English
Word FoodShare Employment and Training - Job Club Appointment Letter F-01255 6/1/2014 English
Word FoodShare Employment and Training - Workshop Appointment Letter F-01257 6/1/2014 English
Word FoodShare Renewal Request for a Closed Case F-00363 1/1/2011 English
Word FoodShare Renewal Request for a Closed Case - Hmong F-00363H 1/1/2011 Hmong
Word FoodShare Renewal Request for a Closed Case - Spanish F-00363S 1/1/2011 Spanish
Word Life Insurance Inquiry F-10144 7/1/2008 English
Word Negative Notice F-16001 7/1/2008 English
Word Negative Notice - Spanish F-16001S 7/1/2008 Spanish
Word Positive Notice F-16015 7/1/2008 English
Word Positive Notice - Spanish F-16015S 7/1/2008 Spanish