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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 (PDF, 81 KB) F-16038 PDF 10/1/2011
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, 46 KB) F-16025 PDF 11/1/2012
English Employment Verification of Earnings F-10146 Word 7/1/2008
English FoodShare and/or Child Care Six Month Report F-16076 Word 1/1/2012
English FoodShare and/or Child Care Six Month Report Form Instructions F-16076A Word 1/1/2012
English FoodShare Employment and Training (FSET) Participation Agreement (PDF, 37 KB) F-00136 PDF 2/1/2012
English FoodShare Renewal Request for a Closed Case F-00363 Word 1/1/2011
English FoodShare Wisconsin Application / Registration (PDF, 215 KB) F-16019B PDF 10/1/2012
English FoodShare Wisconsin Change Report (PDF, 110 KB) F-16006 PDF 2/1/2012
English FoodShare Wisconsin Income Change Report (PDF, 45 KB) F-16066 PDF 10/1/2012
English FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) F-16073 PDF 8/1/2008
English FoodShare Wisconsin Registration / Important Information (PDF, 565 KB) F-16019A PDF 10/1/2012
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 (PDF, 17 KB) F-16104 PDF 11/1/2009
English Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 192 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, 582 KB) F-16024 PDF 7/1/2008
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, 17 KB) F-00330 PDF 2/1/2012
English Self-Employment Income Report (PDF, 38 KB) F-00107 PDF 4/1/2013
English Self-Employment Income Report (Worksheet) (PDF, 31 KB) F-00107W PDF 5/1/2010
English Self-Employment Income Report - Farmer (PDF, 80 KB) F-00219 PDF 5/1/2010
English Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) F-00219W PDF 5/1/2010
English Self-Employment Income Worksheet - Corporation (PDF, 37 KB) F-16034 PDF 2/1/2010
English Self-Employment Income Worksheet - Partnership (PDF, 49 KB) F-16036 PDF 9/1/2012
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 72 KB) F-16037 PDF 9/1/2012
English Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 60 KB) F-16035 PDF 5/1/2009
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 F-00098 Word 6/1/2009
English Waiver of Administrative Disqualification Hearing (PDF, 61 KB) F-16039 PDF 10/1/2011
English Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 86 KB) F-10140 PDF 10/1/2012
English Your Rights and Responsibilities for FoodShare (PDF, 103 KB) F-10150B PDF 10/1/2012
English Your Rights and Responsibilities for Health Care / FoodShare (PDF, 79 KB) F-10150 PDF 10/1/2012
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, 41 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, 243 KB) F-16019BH PDF 10/1/2012
Hmong FoodShare Wisconsin Change Report - Hmong (PDF, 68 KB) F-16006H PDF 2/1/2012
Hmong FoodShare Wisconsin Income Change Report - Hmong (PDF, 38 KB) F-16066H PDF 10/1/2012
Hmong FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 56 KB) F-16019AH PDF 10/1/2012
Hmong Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 242 KB) F-10126H PDF 7/1/2008
Hmong Self-Employment Income Report - Farmer - Hmong (PDF, 69 KB) F-00219H PDF 5/1/2010
Hmong Self-Employment Income Report - Hmong (PDF, 29 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, 31 KB) F-16025S PDF 11/1/2011
Spanish FoodShare and/or Child Care Six Month Report - Spanish F-16076S Word 1/1/2012
Spanish FoodShare and/or Child Care Six Month Report Form Instructions - Spanish F-16076AS Word 1/1/2012
Spanish FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 40 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, 350 KB) F-16019BS PDF 10/1/2012
Spanish FoodShare Wisconsin Change Report - Spanish (PDF, 116 KB) F-16006S PDF 2/1/2012
Spanish FoodShare Wisconsin Income Change Report - Spanish (PDF, 37 KB) F-16066S PDF 10/1/2012
Spanish FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 53 KB) F-16019AS PDF 10/1/2012
Spanish FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) F-16029S PDF 7/1/2008
Spanish Local Agency Customer Feedback - Spanish (PDF, 16 KB) F-16104S PDF 11/1/2009
Spanish Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 529 KB) F-10126S PDF 7/1/2008
Spanish Negative Notice - Spanish (PDF, 200 KB) F-16001S PDF 7/1/2008
Spanish Notice of Disqualification - Spanish (PDF, 867 KB) F-16024S PDF 7/1/2008
Spanish Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) F-16028S PDF 7/1/2008
Spanish Positive Notice - Spanish (PDF, 46 KB) F-16015S PDF 7/1/2008
Spanish Self-Employment Income Report - Farmer - Spanish (PDF, 81 KB) F-00219S PDF 5/1/2010
Spanish Self-Employment Income Report - Spanish (PDF, 29 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, 75 KB) F-16039S PDF 10/1/2011
Spanish Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 90 KB) F-10140S PDF 10/1/2012