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All Income Maintenance (IM) Forms and Worksheets

Below is a list of all Income Maintenance (IM) forms and worksheets.

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

Assigned number Title Release date File type Language Available to order
F-14014S Authorization to Disclose Information to Disability Determination Bureau (DDB), Spanish 03/2022 PDF Spanish No
F-14014H Authorization to Disclose Information to Disability Determination Bureau (DDB), Hmong 03/2022 PDF Hmong No
F-10146 Employer Verification of Earnings 02/2022 Word English No
F-01359 Historical Earnings Verification Request 02/2022 Word English No
F-10193S Divestment Penalty and Undue Hardship Notice Plus Waiver Request, Spanish 08/2021 PDF Spanish No
F-10193 Divestment Penalty and Undue Hardship Notice Plus Waiver Request 08/2021 PDF English No
F-10112A Medicaid - Disability Application Addendum 11/2020 PDF English No
F-10112AS Medicaid - Disability Application Addendum, Spanish 11/2020 PDF Spanish No
F-10112AH Medicaid - Disability Application Addendum, Hmong 11/2020 PDF Hmong No
F-10150BSO Your Rights and Responsibilities for FoodShare, Somali 08/2020 PDF Somali No
F-10150BG Your Rights and Responsibilities for FoodShare, German 08/2020 PDF German No
F-10150BS Your Rights and Responsibilities for FoodShare, Spanish 08/2020 PDF Spanish No
F-10150BR Your Rights and Responsibilities for FoodShare, Russian 08/2020 PDF Russian No
F-10150BCM Your Rights and Responsibilities for FoodShare, Chinese (Simplified) 08/2020 PDF Chinese (Simplified) No
F-10150BH Your Rights and Responsibilities for FoodShare, Hmong 08/2020 PDF Hmong No
F-10150BL Your Rights and Responsibilities for FoodShare, Laotian 08/2020 PDF Lao No
F-10150B Your Rights and Responsibilities for FoodShare 08/2020 PDF English No
F-10150BAR Your Rights and Responsibilities for FoodShare, Arabic 08/2020 PDF Arabic No
F-02642A Report a Change in Circumstance 08/2020 Word English No
F-02642H Report of a Change in Circumstance to Income Maintenance Agencies, Hmong 08/2020 Word Hmong No
F-02642AH Report a Change in Circumstance, Hmong 08/2020 Word Hmong No
F-02642AS Report a Change in Circumstance, Spanish 08/2020 Word Spanish No
F-02642 Report of a Change in Circumstance to Income Maintenance Agencies 08/2020 Word English No
F-02642S Report of a Change in Circumstance to Income Maintenance Agencies, Spanish 08/2020 Word Spanish No
F-16015S Notice of Approval of Benefits/Positive Change in Benefits, Spanish 07/2020 Word Spanish No

Glossary

 
Last revised February 20, 2026