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Eligibility Management (Income Maintenance) Home >> IM Forms

FoodShare Forms by Form Title

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 Title Form Number Form Type Revised Date Language
Enrollment and Benefits Handbook - April 2014 (PDF, 1625 KB) P-00079 PDF 7/1/2014 English
Enrollment and Benefits Handbook - November 2013 (PDF, 3360 KB) P-00079-P PDF 11/1/2013 English
Enrollment and Benefits Handbook - Spanish (PDF, 1839 KB) P-00079S PDF 7/1/2014 Spanish
Access / Marketplace Take Away Card (PDF, 549 KB) P-00555 Paper 1/1/2014 English
Access / Marketplace Take Away Card (Spanish) (PDF, 538 KB) P-00555S Paper 11/1/2013 English
ACCESS Handbook P-16101 HTML 2/1/2014 English
ACCESS Poster (PDF, 445 KB) P-16084 Paper 9/1/2010 English
ACCESS Poster - Spanish (PDF, 448 KB) P-16084S Paper 9/1/2010 Spanish
ACCESS Poster Tear Off Sheet (PDF, 137 KB) P-16084A Paper 9/1/2010 English
ACCESS Poster Tear Off Sheet - Spanish (PDF, 35 KB) P-16084AS Paper 9/1/2010 Spanish
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
Agency Response to the State Quality Assurance (QA) FoodShare (FS) Finding (PDF, 183 KB) F-16050 PDF 7/1/2008 English
And Justice for All Poster P-19004 Paper 2/1/2003 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
Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong (PDF, 31 KB) F-16004H PDF 7/1/2008 Hmong
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 (PDF, 118 KB) F-16060 PDF 10/1/2014 English
Disaster FoodShare Wisconsin Assistance Application - Spanish (PDF, 75 KB) F-16060S PDF 2/1/2012 Spanish
Disqualification Consent Agreement (PDF, 71 KB) F-16025 PDF 2/1/2014 English
Disqualification Consent Agreement - Spanish (PDF, 72 KB) F-16025S PDF 2/1/2014 Spanish
Electronic Case File (ECF) Handbook P-16102 HTML 11/1/2013 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 Instructions - Spanish F-16076AS Word 6/1/2014 Spanish
FoodShare and/or Child Care Six Month Report (Hmong) F-16076H Word 1/1/2012 Hmong
FoodShare and/or Child Care Six Month Report - Spanish F-16076S Word 6/1/2014 Spanish
FoodShare and/or Child Care Six Month Report Form Instructions F-16076A Word 6/1/2014 English
FoodShare and/or Child Care Six Month Report Form Instructions - Hmong F-16076AH Word 1/1/2012 Hmong
FoodShare Employment and Training (FSET) Handbook P-00419 HTML 5/1/2013 English
FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) F-00136 PDF 2/1/2012 English
FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 42 KB) F-00136H PDF 2/1/2012 Hmong
FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 41 KB) F-00136S PDF 2/1/2012 Spanish
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 Renewal Request for a Closed Case - Hmong F-00363H Word 1/1/2011 Hmong
FoodShare Renewal Request for a Closed Case - Spanish F-00363S Word 1/1/2011 Spanish
FoodShare Standard Utility Credits (PDF, 277 KB) P-00654 PDF 10/1/2014 English
FoodShare Standard Utility Credits - Spanish (PDF, 295 KB) P-00654S PDF 10/1/2014 English
FoodShare Wisconsin - FoodShare (SNAP) for Seniors and People with Disabilities Fact Sheet (PDF, 85 KB) P-16013 PDF 6/1/2013 English
FoodShare Wisconsin - FoodShare and / or Child Care Six Month Report Form Fact Sheet (PDF, 141 KB) P-16078 PDF 2/1/2012 English
FoodShare Wisconsin - FoodShare and / or Child Care Six Month Report Form Fact Sheet - Spanish (PDF, 154 KB) P-16078S PDF 2/1/2012 Spanish
FoodShare Wisconsin - FoodShare Employment and Training (FSET) (PDF, 96 KB) P-16092 PDF 6/1/2013 English
FoodShare Wisconsin - FoodShare for Senior Citizens and People with Disabilities Fact Sheet - Spanish (PDF, 98 KB) P-16013S PDF 6/1/2013 Spanish
FoodShare Wisconsin - FoodShare Makes Wisconsin Healthier Brochure (PDF, 548 KB) P-16063 Paper 9/1/2014 English
FoodShare Wisconsin - FoodShare Makes Wisconsin Healthier Brochure (PDF, 567 KB) P-16063H Paper 9/1/2014 English
FoodShare Wisconsin - FoodShare Makes Wisconsin Healthier Brochure - Spanish (PDF, 572 KB) P-16063S Paper 9/1/2014 Spanish
FoodShare Wisconsin - FoodShare Makes Wisconsin Healthier Fact Sheet (PDF, 96 KB) P-16062 PDF 6/1/2014 English
FoodShare Wisconsin - FoodShare Makes Wisconsin Healthier Fact Sheet - Hmong (PDF, 146 KB) P-16062H PDF 6/1/2013 Hmong
FoodShare Wisconsin - FoodShare Makes Wisconsin Healthier Fact Sheet - Spanish (PDF, 154 KB) P-16062S PDF 6/1/2013 Spanish
FoodShare Wisconsin - FoodShare Quality Assurance Review Fact Sheet (PDF, 93 KB) P-16000 PDF 6/1/2013 English
FoodShare Wisconsin - FoodShare Quality Assurance Review Fact Sheet - Hmong (PDF, 93 KB) P-16000H PDF 6/1/2013 Hmong
FoodShare Wisconsin - FoodShare Quality Assurance Review Fact Sheet - Spanish (PDF, 167 KB) P-16000S PDF 6/1/2013 Spanish
FoodShare Wisconsin - FoodShare Wisconsin Handbook P-16001 HTML 2/1/2014 English
FoodShare Wisconsin - QUEST Card Mailer / Wallet Card Only (PDF, 698 KB) P-16075 PDF 7/1/2013 English
FoodShare Wisconsin - QUEST Card Mailer / Wallet Card Only - Hmong (PDF, 729 KB) P-16075H PDF 7/1/2013 Hmong
FoodShare Wisconsin - QUEST Card Mailer / Wallet Card Only - Russian (PDF, 269 KB) P-16075R PDF 7/1/2013 Russian
FoodShare Wisconsin - QUEST Card Mailer / Wallet Card Only - Spanish (PDF, 691 KB) P-16075S PDF 7/1/2013 Spanish
FoodShare Wisconsin - Transitional FoodShare Benefits Fact Sheet (PDF, 171 KB) P-16074 PDF 6/1/2013 English
FoodShare Wisconsin - Transitional FoodShare Benefits Fact Sheet - Spanish (PDF, 165 KB) P-16074S PDF 6/1/2013 Spanish
FoodShare Wisconsin - Your FoodShare Rights Poster (Hmong) (PDF, 304 KB) P-00102H Paper 4/1/2014 Hmong
FoodShare Wisconsin - Your FoodShare Rights Poster (PDF, 137 KB) P-00102 Paper 4/1/2014 English
FoodShare Wisconsin - Your FoodShare Rights Poster (Spanish) (PDF, 257 KB) P-00102S Paper 4/1/2014 Spanish
FoodShare Wisconsin - Your Wisconsin Quest Card Fact Sheet (Hmong) (PDF, 197 KB) P-16088H PDF 6/1/2013 Hmong
FoodShare Wisconsin - Your Wisconsin Quest Card Fact Sheet (PDF, 238 KB) P-16088 PDF 6/1/2014 English
FoodShare Wisconsin - Your Wisconsin Quest Card Fact Sheet (Spanish) (PDF, 193 KB) P-16088S PDF 6/1/2013 Hmong
FoodShare Wisconsin Application / Registration (PDF, 657 KB) F-16019B Paper 4/1/2014 English
FoodShare Wisconsin Application / Registration - Hmong (PDF, 712 KB) F-16019BH PDF 4/1/2014 Hmong
FoodShare Wisconsin Application / Registration - Spanish (PDF, 677 KB) F-16019BS PDF 4/1/2014 Spanish
FoodShare Wisconsin Change Report (PDF, 250 KB) F-16006 Paper 6/1/2013 English
FoodShare Wisconsin Change Report - Arabic (PDF, 121 KB) F-16006AR PDF 6/1/2013 Arabic
FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) F-16006H PDF 6/1/2013 Hmong
FoodShare Wisconsin Change Report - Spanish (PDF, 133 KB) F-16006S PDF 6/1/2013 Spanish
FoodShare Wisconsin Income Change Report (PDF, 70 KB) F-16066 Paper 10/1/2014 English
FoodShare Wisconsin Income Change Report - Arabic (PDF, 146 KB) F-16066AR PDF 10/1/2014 Arabic
FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) F-16066H PDF 10/1/2013 Hmong
FoodShare Wisconsin Income Change Report - Spanish (PDF, 87 KB) F-16066S PDF 10/1/2013 Spanish
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 Registration / Important Information - Hmong (PDF, 238 KB) F-16019AH PDF 4/1/2014 Hmong
FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 299 KB) F-16019AS PDF 4/1/2014 Spanish
FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) F-16029 PDF 7/1/2008 English
FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) F-16029S PDF 7/1/2008 Spanish
FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) F-16030 PDF 7/1/2011 English
FoodShare Work Requirements for Adults Ages 18 through 49 (PDF, 121 KB) P-00710 PDF 10/1/2014 English
FoodShare Worksheet (PDF, 45 KB) F-16033 PDF 7/1/2011 English
Guide to Applying for Wisconsin Health, Nutrition and Other Programs (PDF, 519 KB) P-16091 Paper 10/1/2014 English
Guide to Applying for Wisconsin's Health and Nutrition Programs - Hmong (PDF, 16 KB) P-16091H PDF 6/1/2013 Hmong
Guide to Applying for Wisconsin's Health and Nutrition Programs - Spanish (PDF, 279 KB) P-16091S PDF 1/1/2011 Spanish
Historical Earnings Verification Request F-01359 Word 9/1/2014 English
Income Maintenance Manual P-16100 HTML 5/1/2011 English
Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 PDF 8/1/2011 English
Key Contacts (PDF, 33 KB) P-16108 PDF 8/1/2012 English
Key Contacts - Spanish (PDF, 149 KB) P-16108S PDF 8/1/2012 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
Local Agency Customer Feedback - Spanish (PDF, 29 KB) F-16104S Paper 8/1/2014 Spanish
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 PDF 2/1/2013 English
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H PDF 2/1/2013 Hmong
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S PDF 2/1/2013 Spanish
Milwaukee Enrollment Services (MilES) Contact Poster Tear Off Sheets - Spanish P-00084AS Paper 1/1/2010 Spanish
Milwaukee Enrollment Services (MilES) Contact Poster P-00084 Paper 4/1/2014 English
Milwaukee Enrollment Services (MilES) Contact Poster - Hmong P-00084H Paper 1/1/2010 Hmong
Milwaukee Enrollment Services (MilES) Contact Poster - Spanish P-00084S Paper 1/1/2010 Spanish
Milwaukee Enrollment Services (MilES) Contact Poster Tear Off Sheets P-00084A Paper 5/1/2014 English
Milwaukee Enrollment Services (MilES) Contact Poster Tear Off Sheets - Hmong P-00084AH Paper 1/1/2010 Hmong
Milwaukee Enrollment Services (MilES) Key Contacts (PDF, 92 KB) P-00087 PDF 12/1/2009 English
Milwaukee Enrollment Services (MilES) Key Contacts - Hmong (PDF, 78 KB) P-00087H PDF 12/1/2009 Hmong
Milwaukee Enrollment Services (MilES) Key Contacts - Spanish (PDF, 81 KB) P-00087S PDF 12/1/2009 Spanish
Negative Notice F-16001 Word 7/1/2008 English
Negative Notice (PDF, 154 KB) F-16001 PDF 7/1/2008 English
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 (PDF, 110 KB) F-16024 PDF 2/1/2014 English
Notice of Disqualification - Spanish (PDF, 73 KB) F-16024S PDF 2/1/2014 Spanish
Notice of FoodShare Over issuance (PDF, 288 KB) F-16028 PDF 7/1/2008 English
Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) F-16028S PDF 7/1/2008 Spanish
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
Positive Notice - Spanish F-16015S Word 7/1/2008 Spanish
Positive Notice - Spanish (PDF, 46 KB) F-16015S PDF 7/1/2008 Spanish
Process Help Book P-16103 HTML 7/1/2012 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 Report - Farmer - Hmong (PDF, 82 KB) F-00219H PDF 6/1/2013 Hmong
Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S PDF 6/1/2013 Spanish
Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H PDF 4/1/2013 Hmong
Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S PDF 4/1/2013 Spanish
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
Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H PDF 7/1/2008 Hmong
Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S PDF 7/1/2008 Spanish
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
Waiver of Administrative Disqualification Hearing - Spanish (PDF, 143 KB) F-16039S PDF 2/1/2014 Spanish
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) F-10140 PDF 10/1/2012 English
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) F-10140S PDF 10/1/2012 Spanish
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, 71 KB) F-10150S PDF 9/1/2013 Spanish
Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 PDF 9/1/2013 English