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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
FoodShare Forms by Form Number

Last Revised: October 24, 2008

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