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Eligibility Management (Income Maintenance) Home >> IM Forms

FoodShare Forms by Form Number

Last Revised: March 26, 2014

This list contains all FoodShare program forms that are available from DHCAA. 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 Number Form Title Form Type Revised Date Language
F-00098 Summary of Information Letter (PDF, 224 KB) PDF 6/1/2009 English
F-00107 Self-Employment Income Report (PDF, 91 KB) PDF 5/1/2013 English
F-00107H Self-Employment Income Report - Hmong (PDF, 51 KB) PDF 4/1/2013 Hmong
F-00107S Self-Employment Income Report - Spanish (PDF, 52 KB) PDF 4/1/2013 Spanish
F-00107W Self-Employment Income Report (Worksheet) (PDF, 32 KB) PDF 5/1/2010 English
F-00136 FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) PDF 2/1/2012 English
F-00136H FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 42 KB) PDF 2/1/2012 Hmong
F-00136S FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 41 KB) PDF 2/1/2012 Spanish
F-00219 Self-Employment Income Report - Farmer (PDF, 74 KB) PDF 6/1/2013 English
F-00219H Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) PDF 6/1/2013 Hmong
F-00219S Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) PDF 6/1/2013 Spanish
F-00219W Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) PDF 5/1/2010 English
F-00330 Request for Replacement FoodShare Benefits (PDF, 28 KB) PDF 6/1/2013 English
F-00363 FoodShare Renewal Request for a Closed Case Word 1/1/2011 English
F-00363H FoodShare Renewal Request for a Closed Case - Hmong Word 1/1/2011 Hmong
F-00363S FoodShare Renewal Request for a Closed Case - Spanish Word 1/1/2011 Spanish
F-00628 Consortium Response to the State IM Second Party Review Finding Word 7/1/2012 English
F-00628 Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) PDF 7/1/2012 English
F-01252 FoodShare Employment and Training - Initial Appointment Letter Word 6/1/2014 English
F-01253 FoodShare Employment and Training - Final Notice Appointment Letter Word 6/1/2014 English
F-01254 FoodShare Employment and Training - Employment Plan (EP) Appointment Letter Word 6/1/2014 English
F-01255 FoodShare Employment and Training - Job Club Appointment Letter Word 6/1/2014 English
F-01256 FoodShare Employment and Training - Discuss Participant Appointment Letter Word 6/1/2014 English
F-01257 FoodShare Employment and Training - Workshop Appointment Letter Word 6/1/2014 English
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) PDF 2/1/2013 English
F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) PDF 2/1/2013 Hmong
F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) PDF 2/1/2013 Spanish
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) PDF 7/1/2008 English
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) PDF 10/1/2012 English
F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) PDF 10/1/2012 Spanish
F-10144 Life Insurance Inquiry Word 7/1/2008 English
F-10146 Employment Verification of Earnings Word 6/1/2014 English
F-10150 Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) PDF 9/1/2013 English
F-10150B Your Rights and Responsibilities for FoodShare (PDF, 81 KB) PDF 9/1/2013 English
F-10150BS Your Rights and Responsibilities for FoodShare - Spanish (PDF, 60 KB) PDF 9/1/2013 English
F-10150S Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) PDF 9/1/2013 Spanish
F-16001 Negative Notice Word 7/1/2008 English
F-16001 Negative Notice (PDF, 154 KB) PDF 7/1/2008 English
F-16001S Negative Notice - Spanish Word 7/1/2008 Spanish
F-16001S Negative Notice - Spanish (PDF, 74 KB) PDF 7/1/2008 Spanish
F-16004 Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (PDF, 32 KB) PDF 7/1/2008 English
F-16004H Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong (PDF, 31 KB) PDF 7/1/2008 Hmong
F-16004S Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish (PDF, 33 KB) PDF 7/1/2008 Spanish
F-16006 FoodShare Wisconsin Change Report (PDF, 250 KB) Paper 6/1/2013 English
F-16006H FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) PDF 6/1/2013 Hmong
F-16006S FoodShare Wisconsin Change Report - Spanish (PDF, 133 KB) PDF 6/1/2013 Spanish
F-16011 Quality Assurance (QA) Sample Check List (PDF, 226 KB) PDF 7/1/2008 English
F-16014 Notice of Program Violation (PDF, 43 KB) PDF 7/1/2008 English
F-16015 Positive Notice Word 7/1/2008 English
F-16015 Positive Notice (PDF, 134 KB) PDF 7/1/2008 English
F-16015S Positive Notice - Spanish Word 7/1/2008 Spanish
F-16015S Positive Notice - Spanish (PDF, 46 KB) PDF 7/1/2008 Spanish
F-16019A FoodShare Wisconsin Registration / Important Information (PDF, 170 KB) Paper 4/1/2014 English
F-16019AH FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 238 KB) PDF 4/1/2014 Hmong
F-16019AS FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 299 KB) PDF 4/1/2014 Spanish
F-16019B FoodShare Wisconsin Application / Registration (PDF, 657 KB) Paper 4/1/2014 English
F-16019BH FoodShare Wisconsin Application / Registration - Hmong (PDF, 712 KB) PDF 4/1/2014 Hmong
F-16019BS FoodShare Wisconsin Application / Registration - Spanish (PDF, 677 KB) PDF 4/1/2014 Spanish
F-16022 Social Security Number Referral (PDF, 61 KB) PDF 7/1/2008 English
F-16022H Social Security Number Referral - Hmong (PDF, 28 KB) PDF 7/1/2008 Hmong
F-16022S Social Security Number Referral - Spanish (PDF, 26 KB) PDF 7/1/2008 Spanish
F-16023 Striker Evaluation (PDF, 395 KB) PDF 7/1/2008 English
F-16024 Notice of Disqualification (PDF, 110 KB) PDF 2/1/2014 English
F-16024S Notice of Disqualification - Spanish (PDF, 73 KB) PDF 2/1/2014 Spanish
F-16025 Disqualification Consent Agreement (PDF, 71 KB) PDF 2/1/2014 English
F-16025S Disqualification Consent Agreement - Spanish (PDF, 72 KB) PDF 2/1/2014 Spanish
F-16026 Prosecution Diversion Agreement (PDF, 251 KB) PDF 7/1/2008 English
F-16028 Notice of FoodShare Over issuance (PDF, 288 KB) PDF 7/1/2008 English
F-16028S Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) PDF 7/1/2008 Spanish
F-16029 FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) PDF 7/1/2008 English
F-16029S FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) PDF 7/1/2008 Spanish
F-16030 FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) PDF 7/1/2011 English
F-16033 FoodShare Worksheet (PDF, 45 KB) PDF 7/1/2011 English
F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) PDF 2/1/2014 English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) PDF 2/1/2014 English
F-16036 Self-Employment Income Worksheet - Partnership (PDF, 27 KB) PDF 2/1/2014 English
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) PDF 2/1/2014 English
F-16037A Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) PDF 6/1/2014 English
F-16038 Administrative Disqualification Hearing Notice (PDF, 101 KB) PDF 2/1/2014 English
F-16039 Waiver of Administrative Disqualification Hearing (PDF, 141 KB) PDF 2/1/2014 English
F-16039S Waiver of Administrative Disqualification Hearing - Spanish (PDF, 143 KB) PDF 2/1/2014 Spanish
F-16060 Disaster FoodShare Wisconsin Assistance Application (PDF, 67 KB) PDF 2/1/2012 English
F-16060S Disaster FoodShare Wisconsin Assistance Application - Spanish (PDF, 75 KB) PDF 2/1/2012 Spanish
F-16066 FoodShare Wisconsin Income Change Report (PDF, 171 KB) Paper 10/1/2013 English
F-16066H FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) PDF 10/1/2013 Hmong
F-16066S FoodShare Wisconsin Income Change Report - Spanish (PDF, 87 KB) PDF 10/1/2013 Spanish
F-16073 FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) PDF 8/1/2008 English
F-16076 FoodShare and/or Child Care Six Month Report Word 6/1/2014 English
F-16076A FoodShare and/or Child Care Six Month Report Form Instructions Word 6/1/2014 English
F-16076AH FoodShare and/or Child Care Six Month Report Form Instructions - Hmong Word 1/1/2012 Hmong
F-16076AS FoodShare and/or Child Care Six Month Report Instructions - Spanish Word 6/1/2014 Spanish
F-16076H FoodShare and/or Child Care Six Month Report (Hmong) Word 1/1/2012 Hmong
F-16076S FoodShare and/or Child Care Six Month Report - Spanish Word 6/1/2014 Spanish
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) PDF 8/1/2011 English
F-16104 Local Agency Customer Feedback (PDF, 17 KB) Paper 11/1/2009 English
F-16104H Local Agency Customer Feedback (PDF, 17 KB) PDF 11/1/2009 English
F-16104S Local Agency Customer Feedback - Spanish (PDF, 16 KB) Paper 11/1/2009 Spanish
F-19002 Affidavit of Return or Exchange of Food Coupons (PDF, 615 KB) PDF 12/1/1997 English