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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: July 12, 2010

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
PDF Administrative Disqualification Hearing Notice (PDF, 81 KB) F-16038 10/1/2011 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, 46 KB) F-16025 11/1/2012 English
PDF Disqualification Consent Agreement - Spanish (PDF, 31 KB) F-16025S 11/1/2011 Spanish
PDF FoodShare Employment and Training (FSET) Participation Agreement (PDF, 37 KB) F-00136 2/1/2012 English
PDF FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 41 KB) F-00136H 2/1/2012 Hmong
PDF FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 40 KB) F-00136S 2/1/2012 Spanish
PDF FoodShare Wisconsin Application / Registration (PDF, 215 KB) F-16019B 10/1/2012 English
PDF FoodShare Wisconsin Application / Registration - Hmong (PDF, 243 KB) F-16019BH 10/1/2012 Hmong
PDF FoodShare Wisconsin Application / Registration - Spanish (PDF, 350 KB) F-16019BS 10/1/2012 Spanish
PDF FoodShare Wisconsin Change Report (PDF, 110 KB) F-16006 2/1/2012 English
PDF FoodShare Wisconsin Change Report - Hmong (PDF, 68 KB) F-16006H 2/1/2012 Hmong
PDF FoodShare Wisconsin Change Report - Spanish (PDF, 116 KB) F-16006S 2/1/2012 Spanish
PDF FoodShare Wisconsin Income Change Report (PDF, 45 KB) F-16066 10/1/2012 English
PDF FoodShare Wisconsin Income Change Report - Hmong (PDF, 38 KB) F-16066H 10/1/2012 Hmong
PDF FoodShare Wisconsin Income Change Report - Spanish (PDF, 37 KB) F-16066S 10/1/2012 Spanish
PDF FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) F-16073 8/1/2008 English
PDF FoodShare Wisconsin Registration / Important Information (PDF, 565 KB) F-16019A 10/1/2012 English
PDF FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 56 KB) F-16019AH 10/1/2012 Hmong
PDF FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 53 KB) F-16019AS 10/1/2012 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 (PDF, 17 KB) F-16104 11/1/2009 English
PDF Local Agency Customer Feedback - Spanish (PDF, 16 KB) F-16104S 11/1/2009 Spanish
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 192 KB) F-10126 2/1/2013 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 242 KB) F-10126H 7/1/2008 Hmong
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 529 KB) F-10126S 7/1/2008 Spanish
PDF Negative Notice (PDF, 154 KB) F-16001 7/1/2008 English
PDF Negative Notice - Spanish (PDF, 200 KB) F-16001S 7/1/2008 Spanish
PDF Notice of Disqualification (PDF, 582 KB) F-16024 7/1/2008 English
PDF Notice of Disqualification - Spanish (PDF, 867 KB) F-16024S 7/1/2008 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, 17 KB) F-00330 2/1/2012 English
PDF Self-Employment Income Report (PDF, 38 KB) F-00107 4/1/2013 English
PDF Self-Employment Income Report (Worksheet) (PDF, 31 KB) F-00107W 5/1/2010 English
PDF Self-Employment Income Report - Farmer (PDF, 80 KB) F-00219 5/1/2010 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, 69 KB) F-00219H 5/1/2010 Hmong
PDF Self-Employment Income Report - Farmer - Spanish (PDF, 81 KB) F-00219S 5/1/2010 Spanish
PDF Self-Employment Income Report - Hmong (PDF, 29 KB) F-00107H 4/1/2013 Hmong
PDF Self-Employment Income Report - Spanish (PDF, 29 KB) F-00107S 4/1/2013 Spanish
PDF Self-Employment Income Worksheet - Corporation (PDF, 37 KB) F-16034 2/1/2010 English
PDF Self-Employment Income Worksheet - Partnership (PDF, 49 KB) F-16036 9/1/2012 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 72 KB) F-16037 9/1/2012 English
PDF Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 60 KB) F-16035 5/1/2009 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 Waiver of Administrative Disqualification Hearing (PDF, 61 KB) F-16039 10/1/2011 English
PDF Waiver of Administrative Disqualification Hearing - Spanish (PDF, 75 KB) F-16039S 10/1/2011 Spanish
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 86 KB) F-10140 10/1/2012 English
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 90 KB) F-10140S 10/1/2012 Spanish
PDF Your Rights and Responsibilities for FoodShare (PDF, 103 KB) F-10150B 10/1/2012 English
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 79 KB) F-10150 10/1/2012 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 7/1/2008 English
Word FoodShare and/or Child Care Six Month Report F-16076 1/1/2012 English
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 1/1/2012 Spanish
Word FoodShare and/or Child Care Six Month Report Form Instructions F-16076A 1/1/2012 English
Word FoodShare and/or Child Care Six Month Report Form Instructions - Hmong F-16076AH 1/1/2012 Hmong
Word FoodShare and/or Child Care Six Month Report Form Instructions - Spanish F-16076AS 1/1/2012 Spanish
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 Positive Notice F-16015 7/1/2008 English
Word Summary of Information Letter F-00098 6/1/2009 English