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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Financing (DHCF)
FoodShare Forms by Form Type

Last Revised: October 24, 2008

This list contains all FoodShare program forms that are available from DHCF sorted by the format (Excel, Paper only, PDF, Word). 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 Type Form Title Form Number Revised Date Language
PDF - Fillable Administrative Disqualification Hearing Notice F-16038 1/1/2008 English
PDF - Fillable Affidavit of Lost Income or Disaster Related Costs F-16106 6/1/2008 English
PDF - Fillable Affidavit of Return or Exchange of Food Coupons F-09002 12/1/1997 English
PDF - Fillable Agency Response to the State Quality Assurance (QA) FoodShare (FS) Finding F-16050 4/1/2007 English
PDF - Fillable BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 7/1/2008 English
PDF - Fillable Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits F-16004 5/1/2008 English
PDF - Fillable Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (Russian) F-16004R 5/1/2008 Russian
PDF - Fillable Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - (Hmong) F-16004H 5/1/2008 Hmong
PDF - Fillable Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - (Spanish) F-16004S 5/1/2008 Spanish
PDF - Fillable Disaster FoodShare Notice F-16105 6/1/2008 English
PDF - Fillable Disaster FoodShare Wisconsin Assistance Application F-16060 6/1/2008 English
PDF - Fillable Disqualification Consent Agreement F-16025 1/1/2008 English
PDF - Fillable Disqualification Consent Agreement (Spanish) F-16025S 1/1/2008 Spanish
PDF - Fillable FoodShare and/or Child Care Six Month Report F-16076 6/1/2005 English
PDF - Fillable FoodShare and/or Child Care Six Month Report (Spanish) F-16076S 6/1/2005 Spanish
PDF - Fillable FoodShare Program Income Change Report - Russian F-16066R 10/1/2006 Russian
PDF - Fillable FoodShare Wisconsin Application / Registration F-16019B 10/1/2008 English
PDF - Fillable FoodShare Wisconsin Application / Registration (Hmong) F-16019BH 12/1/2004 Hmong
PDF - Fillable FoodShare Wisconsin Application / Registration (Russian) F-16019BR 12/1/2004 Russian
PDF - Fillable FoodShare Wisconsin Application / Registration (Spanish) F-16019BS 12/1/2004 Spanish
PDF - Fillable FoodShare Wisconsin Change Report F-16006 8/1/2008 English
PDF - Fillable FoodShare Wisconsin Change Report - Hmong F-16006H 10/1/2004 Hmong
PDF - Fillable FoodShare Wisconsin Change Report - Russian F-16006R 10/1/2004 Russian
PDF - Fillable FoodShare Wisconsin Change Report - Spanish F-16006S 10/1/2004 Spanish
PDF - Fillable FoodShare Wisconsin Income Change Report F-16066 10/1/2007 English
PDF - Fillable FoodShare Wisconsin Income Change Report - Hmong F-16066H 10/1/2006 Hmong
PDF - Fillable FoodShare Wisconsin Income Change Report - Spanish F-16066S 10/1/2006 Spanish
PDF - Fillable FoodShare Wisconsin Over Issuance Worksheet F-16030 10/1/2008 English
PDF - Fillable FoodShare Wisconsin Registration / Important Information F-16019A 10/1/2008 English
PDF - Fillable FoodShare Wisconsin Registration Important Information (Hmong) F-16019AH 12/1/2004 Hmong
PDF - Fillable FoodShare Wisconsin Registration Important Information (Russian) F-16019AR 12/1/2004 Russian
PDF - Fillable FoodShare Wisconsin Registration Important Information (Spanish) F-16019AS 12/1/2004 Spanish
PDF - Fillable FoodShare Wisconsin Repayment Agreement F-16029 3/1/2008 English
PDF - Fillable FoodShare Wisconsin Repayment Agreement (Spanish) F-16029S 3/1/2008 Spanish
PDF - Fillable FoodShare Wisconsin Worksheet F-16033 10/1/2008 English
PDF - Fillable Income Maintenance Quality Assurance (IMQA) Web Request F-16083 4/1/2005 English
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 7/1/2008 English
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) F-10126H 7/1/2008 Hmong
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) F-10126S 7/1/2008 Spanish
PDF - Fillable Negative Notice F-16001 1/1/2008 English
PDF - Fillable Negative Notice - Spanish F-16001S 4/1/2006 Spanish
PDF - Fillable Notice of Disqualification F-16024 8/1/2007 English
PDF - Fillable Notice of Disqualification (Spanish) F-16024S 8/1/2007 Spanish
PDF - Fillable Notice of FoodShare Over issuance F-16028 3/1/2008 English
PDF - Fillable Notice of FoodShare Over issuance (Spanish) F-16028S 3/1/2008 Spanish
PDF - Fillable Notice of Program Violation F-16014 4/1/2005 English
PDF - Fillable Positive Notice F-16015 1/1/2008 English
PDF - Fillable Positive Notice - Spanish F-16015S 4/1/2006 Spanish
PDF - Fillable Prosecution Diversion Agreement F-16026 5/1/2005 English
PDF - Fillable Quality Assurance (QA) Sample Check List F-16011 5/1/2005 English
PDF - Fillable Quest Card and PIN Responsibility Statement F-16007 10/1/2005 English
PDF - Fillable Quest Card and Pin Responsibility Statement - Hmong F-16007H 10/1/2005 Hmong
PDF - Fillable Quest Card and Pin Responsibility Statement - Russian F-16007R 10/1/2005 English
PDF - Fillable Quest Card and Pin Responsibility Statement - Spanish F-16007S 10/1/2005 English
PDF - Fillable Self-Employment Income Worksheet - Corporation F-16034 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Partnership F-16036 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Subchapter S Corporation F-16035 3/1/2008 English
PDF - Fillable Social Security Number Referral F-16022 1/1/2008 English
PDF - Fillable Striker Evaluation F-16023 10/1/2004 English
PDF - Fillable Waiver of Administrative Disqualification Hearing F-16039 4/1/2005 English
PDF - Fillable Waiver of Administrative Disqualification Hearing (Spanish) F-16039S 4/1/2005 Spanish
PDF - Fillable Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 7/1/2008 English
PDF - Fillable Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (Spanish) F-10140S 7/1/2008 Spanish
PDF - Print FoodShare and/or Child Care Six Month Report Form Instructions F-16076A 6/1/2005 English
PDF - Print FoodShare and/or Child Care Six Month Report Form Instructions (Spanish) F-16076AS 6/1/2005 Spanish
PDF - Print FoodShare Wisconsin Nonfinancial Worksheet F-16073 8/1/2008 English
PDF - Print Local Agency Customer Feedback F-16104 8/1/2007 English
PDF - Print Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin F-10150 8/1/2007 English
PDF - Print Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish F-10150S 5/1/2007 Spanish
Word - Fillable Employment Verification of Earnings F-10146 12/1/2007 English
Word - Fillable Life Insurance Inquiry F-10144 7/1/2008 English