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Eligibility Management (Income Maintenance) Home >> IM Forms

FoodShare Forms by Language

Last Revised: March 26, 2014

This list contains all FoodShare program forms that are available from DHCAA sorted by the language in which they are written. 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.

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