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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Financing (DHCF) 

Income Maintenance Forms
FoodShare Forms by Language

Last Revised: July 14, 2008

This list contains all FoodShare program forms that are available from DHCF sorted by the language in which they are written. 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.

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