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Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: July 14, 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 Title Form Number Form Type Revised Date Language
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
Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (Russian) F-16004R PDF - Fillable 5/1/2008 Russian
Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - (Hmong) F-16004H PDF - Fillable 5/1/2008 Hmong
Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - (Spanish) F-16004S PDF - Fillable 5/1/2008 Spanish
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
Disqualification Consent Agreement (Spanish) F-16025S PDF - Fillable 1/1/2008 Spanish
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 (Spanish) F-16076S PDF - Fillable 6/1/2005 Spanish
FoodShare and/or Child Care Six Month Report Form Instructions F-16076A PDF - Print 6/1/2005 English
FoodShare and/or Child Care Six Month Report Form Instructions (Spanish) F-16076AS PDF - Print 6/1/2005 Spanish
FoodShare Program Income Change Report - Russian F-16066R PDF - Fillable 10/1/2006 Russian
FoodShare Wisconsin Application / Registration F-16019B PDF - Fillable 12/1/2004 English
FoodShare Wisconsin Application / Registration (Hmong) F-16019BH PDF - Fillable 12/1/2004 Hmong
FoodShare Wisconsin Application / Registration (Russian) F-16019BR PDF - Fillable 12/1/2004 Russian
FoodShare Wisconsin Application / Registration (Spanish) F-16019BS PDF - Fillable 12/1/2004 Spanish
FoodShare Wisconsin Change Report F-16006 PDF - Fillable 8/1/2008 English
FoodShare Wisconsin Change Report - Hmong F-16006H PDF - Fillable 10/1/2004 Hmong
FoodShare Wisconsin Change Report - Russian F-16006R PDF - Fillable 10/1/2004 Russian
FoodShare Wisconsin Change Report - Spanish F-16006S PDF - Fillable 10/1/2004 Spanish
FoodShare Wisconsin Income Change Report F-16066 PDF - Fillable 10/1/2007 English
FoodShare Wisconsin Income Change Report - Hmong F-16066H PDF - Fillable 10/1/2006 Hmong
FoodShare Wisconsin Income Change Report - Spanish F-16066S PDF - Fillable 10/1/2006 Spanish
FoodShare Wisconsin Nonfinancial Worksheet F-16073 PDF - Print 8/1/2008 English
FoodShare Wisconsin Over issuance Worksheet F-16030 PDF - Fillable 4/1/2008 English
FoodShare Wisconsin Registration / Important Information F-16019A PDF - Fillable 4/1/2007 English
FoodShare Wisconsin Registration Important Information (Hmong) F-16019AH PDF - Fillable 12/1/2004 Hmong
FoodShare Wisconsin Registration Important Information (Russian) F-16019AR PDF - Fillable 12/1/2004 Russian
FoodShare Wisconsin Registration Important Information (Spanish) F-16019AS PDF - Fillable 12/1/2004 Spanish
FoodShare Wisconsin Repayment Agreement F-16029 PDF - Fillable 3/1/2008 English
FoodShare Wisconsin Repayment Agreement (Spanish) F-16029S PDF - Fillable 3/1/2008 Spanish
FoodShare Wisconsin Worksheet F-16033 PDF - Fillable 6/1/2007 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
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) F-10126H PDF - Fillable 2/1/2008 Hmong
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) F-10126S PDF - Fillable 2/1/2008 Spanish
Negative Notice F-16001 PDF - Fillable 1/1/2008 English
Negative Notice - Spanish F-16001S PDF - Fillable 4/1/2006 Spanish
Notice of Disqualification F-16024 PDF - Fillable 8/1/2007 English
Notice of Disqualification (Spanish) F-16024S PDF - Fillable 8/1/2007 Spanish
Notice of FoodShare Over issuance F-16028 PDF - Fillable 3/1/2008 English
Notice of FoodShare Over issuance (Spanish) F-16028S PDF - Fillable 3/1/2008 Spanish
Notice of Program Violation F-16014 PDF - Fillable 4/1/2005 English
Positive Notice F-16015 PDF - Fillable 1/1/2008 English
Positive Notice - Spanish F-16015S PDF - Fillable 4/1/2006 Spanish
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 - Hmong F-16007H PDF - Fillable 10/1/2005 Hmong
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
Waiver of Administrative Disqualification Hearing (Spanish) F-16039S PDF - Fillable 4/1/2005 Spanish
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 PDF - Fillable 2/1/2008 English
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 F-10150 PDF - Print 8/1/2007 English
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 Spanish