All Income Maintenance (IM) Forms

Clicking the Assigned Number link will either download the selected form (if only one version is available) OR it will open a page that will display all language versions of that form. From that page you can choose and download the needed forms.
Assigned Numbersort descending Title Other Location
F-00098 Summary of Information Letter (PDF, 224 KB)
F-00100 State Vital Records Cover Letter
F-00101 Authorization to Request Birth Records
F-00107 Self-Employment Income Report
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB)
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-00219 Self-Employment Income Report - Farmer
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB)
F-00233 Renewal Summary Letter
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB)
F-00330 Request for Replacement FoodShare Benefits
F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB)
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application (PDF, 25 KB)
F-00407 Financial Records Request (PDF, 28 KB)
F-00628 Consortium Response to the State IM Second Party Review Finding
F-00639 Agency Data Security Staff User Agreement
F-00685 Statement of Tribal Affiliation (PDF, 24 KB)
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment
F-01256 FoodShare Employment and Training (FSET) - Discuss FSET Participation
F-01257 FoodShare Employment and Training (FSET) - Workshop Appointment
F-01359 Historical Earnings Verification Request
F-01542 Notification of Required Drug Testing
F-01598 Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents
F-01983 Self-Employment Income Worksheet: Business Capital Gains or Losses (Form 4797)
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E)
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-10075 Wisconsin Well Woman Medicaid Determination (PDF, 78 KB)
F-10076 SeniorCare Application
F-10080 SeniorCare Authorization of Representative (PDF, 486 KB)
F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application
F-10093 Medicaid and BadgerCare Plus Overpayment Notice
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse
F-10096 Community Spouse Asset Share Notice
F-10097 Medicaid Income Allocation Notice
F-10098 Medicaid Member Asset Allocation Notice
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-10108 Medicaid Manual Notice for Cost of Care Contribution
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB)
F-10110 Medicaid / BadgerCare Plus Certification
F-10111 Good Faith Medicaid / BadgerCare Plus Certification
F-10112 Medicaid Disability Application
F-10114 Medicaid Disability Redetermination Report (PDF, 222 KB)
F-10115 BadgerCare Plus / Medicaid Health Insurance Information

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Last Revised: December 18, 2014