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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA) FoodShare Forms by Language

Last Revised: July 12, 2010

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 F-16038 PDF 10/1/2011
English Affidavit of Return or Exchange of Food Coupons F-19002 PDF 12/1/1997
English BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 PDF 7/1/2008
English Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits F-16004 PDF 7/1/2008
English Disaster FoodShare Program Notice F-16105 Word 11/1/2010
English Disaster FoodShare Wisconsin Assistance Application F-16060 PDF 7/1/2008
English Disqualification Consent Agreement F-16025 PDF 11/1/2011
English Employment Verification of Earnings F-10146 Word 7/1/2008
English FoodShare and/or Child Care Six Month Report F-16076 PDF 7/1/2008
English FoodShare and/or Child Care Six Month Report Form Instructions F-16076A PDF 7/1/2008
English FoodShare Employment and Training (FSET) Participation Agreement F-00136 PDF 7/1/2009
English FoodShare Renewal Request for a Closed Case F-00363 Word 1/1/2011
English FoodShare Wisconsin Application / Registration F-16019B PDF 6/1/2011
English FoodShare Wisconsin Change Report F-16006 PDF 8/1/2008
English FoodShare Wisconsin Income Change Report F-16066 PDF 10/1/2011
English FoodShare Wisconsin Nonfinancial Worksheet F-16073 PDF 8/1/2008
English FoodShare Wisconsin Registration / Important Information F-16019A PDF 2/1/2011
English FoodShare Wisconsin Repayment Agreement F-16029 PDF 7/1/2008
English FoodShare Wisconsin Under / Over Issuance Worksheet F-16030 PDF 7/1/2011
English FoodShare Worksheet F-16033 PDF 7/1/2011
English Income Maintenance Quality Assurance (IMQA) Web Request F-16083 PDF 8/1/2011
English Life Insurance Inquiry F-10144 Word 7/1/2008
English Local Agency Customer Feedback F-16104 PDF 11/1/2009
English Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 PDF 7/1/2008
English Negative Notice F-16001 PDF 7/1/2008
English Negative Notice F-16001 Word 7/1/2008
English Notice of Disqualification F-16024 PDF 7/1/2008
English Notice of FoodShare Over issuance F-16028 PDF 7/1/2008
English Notice of Program Violation F-16014 PDF 7/1/2008
English Positive Notice F-16015 PDF 7/1/2008
English Positive Notice F-16015 Word 7/1/2008
English Prosecution Diversion Agreement F-16026 PDF 7/1/2008
English Quality Assurance (QA) Sample Check List F-16011 PDF 7/1/2008
English Request for Replacement FoodShare Benefits F-00330 PDF 11/1/2010
English Self-Employment Income Report F-00107 PDF 5/1/2010
English Self-Employment Income Report (Worksheet) F-00107W PDF 5/1/2010
English Self-Employment Income Report - Farmer F-00219 PDF 5/1/2010
English Self-Employment Income Report - Farmer (Worksheet) F-00219W PDF 5/1/2010
English Self-Employment Income Worksheet - Corporation F-16034 PDF 2/1/2010
English Self-Employment Income Worksheet - Partnership F-16036 PDF 5/1/2009
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 PDF 5/1/2009
English Self-Employment Income Worksheet - Subchapter S Corporation F-16035 PDF 5/1/2009
English Social Security Number Referral F-16022 PDF 7/1/2008
English Striker Evaluation F-16023 PDF 7/1/2008
English Summary of Information Letter F-00098 Word 6/1/2009
English Supplemental Disaster FoodShare Program (DFSP) Affidavit F-00325 PDF 11/1/2010
English Waiver of Administrative Disqualification Hearing F-16039 PDF 10/1/2011
English Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 PDF 7/1/2008
English Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin F-10150 PDF 7/1/2008
Hmong Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong F-16004H PDF 7/1/2008
Hmong FoodShare Employment and Training (FSET) Participation Agreement - Hmong F-00136H PDF 7/1/2009
Hmong FoodShare Renewal Request for a Closed Case - Hmong F-00363H Word 1/1/2011
Hmong FoodShare Wisconsin Application / Registration - Hmong F-16019BH PDF 2/1/2011
Hmong FoodShare Wisconsin Change Report - Hmong F-16006H PDF 7/1/2008
Hmong FoodShare Wisconsin Income Change Report - Hmong F-16066H PDF 10/1/2008
Hmong FoodShare Wisconsin Registration Important Information - Hmong F-16019AH PDF 2/1/2011
Hmong Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong F-10126H PDF 7/1/2008
Hmong Self-Employment Income Report - Farmer - Hmong F-00219H PDF 5/1/2010
Hmong Self-Employment Income Report - Hmong F-00107H PDF 5/1/2010
Hmong Social Security Number Referral - Hmong F-16022H PDF 7/1/2008
Russian Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Russian F-16004R PDF 7/1/2008
Russian FoodShare Wisconsin Change Report - Russian F-16006R PDF 7/1/2008
Spanish Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish F-16004S PDF 7/1/2008
Spanish Disaster FoodShare Wisconsin Assistance Application - Spanish F-16060S PDF 7/1/2008
Spanish Disqualification Consent Agreement - Spanish F-16025S PDF 11/1/2011
Spanish FoodShare and/or Child Care Six Month Report - Spanish F-16076S PDF 7/1/2008
Spanish FoodShare and/or Child Care Six Month Report Form Instructions - Spanish F-16076AS PDF 7/1/2008
Spanish FoodShare Employment and Training (FSET) Participation Agreement - Spanish F-00136S PDF 7/1/2009
Spanish FoodShare Renewal Request for a Closed Case - Spanish F-00363S Word 1/1/2011
Spanish FoodShare Wisconsin Application / Registration - Spanish F-16019BS PDF 2/1/2011
Spanish FoodShare Wisconsin Change Report - Spanish F-16006S PDF 7/1/2008
Spanish FoodShare Wisconsin Income Change Report - Spanish F-16066S PDF 10/1/2008
Spanish FoodShare Wisconsin Registration Important Information - Spanish F-16019AS PDF 2/1/2011
Spanish FoodShare Wisconsin Repayment Agreement - Spanish F-16029S PDF 7/1/2008
Spanish Local Agency Customer Feedback - Spanish F-16104S PDF 11/1/2009
Spanish Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish F-10126S PDF 7/1/2008
Spanish Negative Notice - Spanish F-16001S PDF 7/1/2008
Spanish Notice of Disqualification - Spanish F-16024S PDF 7/1/2008
Spanish Notice of FoodShare Overissuance - Spanish F-16028S PDF 7/1/2008
Spanish Positive Notice - Spanish F-16015S PDF 7/1/2008
Spanish Self-Employment Income Report - Farmer - Spanish F-00219S PDF 5/1/2010
Spanish Self-Employment Income Report - Spanish F-00107S PDF 5/1/2010
Spanish Social Security Number Referral - Spanish F-16022S PDF 7/1/2008
Spanish Supplemental Disaster FoodShare Program (DFSP) Affidavit - Spanish F-00325S PDF 11/1/2010
Spanish Waiver of Administrative Disqualification Hearing - Spanish F-16039S PDF 10/1/2011
Spanish Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish F-10140S PDF 7/1/2008
Spanish Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin - Spanish F-10150S PDF 7/1/2008