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Caretaker Supplement Forms

Below is a list of all Caretaker Supplement forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned number Title Division Language Release date Available to order
F-22565 Authorization for Recoupment Caretaker Supplement (Word) DMS English 09/2019 No
F-22565 Authorization for Recoupment Caretaker Supplement (CTS) (PDF) DMS English 09/2019 No
F-22564 Authorization for Retroactive Caretaker Supplement (CTS) (PDF) DMS English 07/2008 No
F-22571A Caretaker Supplement (CTS) Instructions for Application (PDF) DMS English 12/2023 No
F-22571AS Caretaker Supplement (CTS) Instructions for Application, Spanish (PDF) DMS Spanish 12/2023 No
F-22571 Caretaker Supplement Application (PDF) DMS English 12/2023 No
F-00107A Instructions, Self-Employment Income Report (PDF) DMS English 04/2026 No
F-00107ACM Instructions, Self-Employment Income Report, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 04/2026 No
F-00107AH Instructions, Self-Employment Income Report, Hmong (PDF) DMS Hmong 04/2026 No
F-00107AS Instructions, Self-Employment Income Report, Spanish (PDF) DMS Spanish 04/2026 No
F-02577 Proof of In-Kind Hours (PDF) DMS English 06/2023 No
F-02577H Proof of In-Kind Hours, Hmong (PDF) DMS Hmong 06/2023 No
F-02577S Proof of In-Kind Hours, Spanish (PDF) DMS Spanish 06/2023 No
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement (PDF) DMS English 05/2023 No
F-02340AR Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Arabic (PDF) DMS Arabic 05/2023 No
F-02340CM Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 05/2023 No
F-02340G Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, German (PDF) DMS German 05/2023 No
F-02340H Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Hmong (PDF) DMS Hmong 05/2023 No
F-02340L Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Laotian (PDF) DMS Lao 05/2023 No
F-02340LP Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Large Print (PDF) DMS English 05/2023 No
F-02340R Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Russian (PDF) DMS Russian 05/2023 No
F-02340SO Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Somali (PDF) DMS Somali 05/2023 No
F-02340S Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, Spanish (PDF) DMS Spanish 05/2023 No
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate (PDF) DMS English 06/2015 No
F-00107 Self-Employment Income Report (PDF) DMS English 05/2026 No
F-00107CM Self-Employment Income Report, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 05/2026 No
F-00107H Self-Employment Income Report, Hmong (PDF) DMS Hmong 05/2026 No
F-00107S Self-Employment Income Report, Spanish (PDF) DMS Spanish 05/2026 No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised September 30, 2025