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 Number Title Division Other Location
F-10183 Information Change Report DMS
F-10076 SeniorCare Application DMS
F-16019B FoodShare Wisconsin Registration Packet DMS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-16033 FoodShare Worksheet DMS
F-16028 Notice of FoodShare Overissuance DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-00330 Request for Replacement FoodShare Benefits DMS
F-16019A FoodShare Wisconsin Registration DMS
F-10182 BadgerCare Plus Application Packet DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-16026 Prosecution Diversion Agreement DMS
F-16024 FoodShare Notice of Disqualification DMS
F-16025 Disqualification Consent Agreement DMS
F-16029 FoodShare Wisconsin Repayment Agreement DMS
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application DMS
F-00107 Self-Employment Income Report DMS
F-01542 Notification of Required Drug Testing DMS
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-10097 Medicaid Income Allocation Notice DMS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-10112 Medicaid Disability Application DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-22565 Authorization for Recoupment Caretaker Supplement DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) DMS
F-01359 Historical Earnings Verification Request DMS
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DMS
F-10146 Employer Verification of Earnings DMS
F-00233 Renewal Summary Letter DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-10150A Your Rights and Responsibilities for Health Care DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-00685 Statement of Tribal Affiliation DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00098 Summary of Information Letter DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-00101 Authorization to Request Birth Records DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-00407 Financial Records Request DMS

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Last Revised: April 11, 2018