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Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: July 12, 2010

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