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Eligibility Management (Income Maintenance) Home >> IM Forms

All Income Maintenance (IM) Forms
Sorted by Form Number

Last Revised: October 24, 2008

This list contains all DHCAA forms that are available from this site. 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-10075 Wisconsin Well Woman Medicaid Determination PDF - Fillable 7/1/2006 English
F-10076 SeniorCare Application PDF - Print 7/1/2003 English
F-10076A SeniorCare Instructions for Application Form PDF - Print 5/1/2008 English
F-10076AH SeniorCare Instructions for Application Form - Hmong PDF - Print 10/1/2005 Hmong
F-10076AR SeniorCare Instructions for Application Form - Russian PDF - Print 10/1/2005 Russian
F-10076AS SeniorCare Instructions for Application Form - Spanish PDF - Print 10/1/2005 Spanish
F-10080 SeniorCare Authorization of Representative PDF - Fillable 7/1/2008 English
F-10093 Medicaid / BadgerCare Plus Overpayment Notice PDF - Fillable 7/1/2008 English
F-10093S Medicaid / BadgerCare Overpayment Notice - Spanish PDF - Fillable 3/1/2005 Spanish
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse PDF - Fillable 7/1/2008 English
F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (Spanish) PDF - Fillable 7/1/2008 Spanish
F-10096 Community Spouse Asset Share Notice PDF - Fillable 7/1/2008 English
F-10097 Medicaid Income Allocation Notice PDF - Fillable 7/1/2008 English
F-10098 Medicaid Member Asset Allocation Notice PDF - Fillable 7/1/2008 English
F-10099 Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility PDF - Fillable 7/1/2008 English
F-10101 Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet PDF - Fillable 8/1/2008 English
F-10101H Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Hmong) PDF - Fillable 7/1/2008 Hmong
F-10101R Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Russian) PDF - Fillable 7/1/2008 Russian
F-10101S Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Spanish) PDF - Fillable 7/1/2008 Spanish
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice PDF - Fillable 7/1/2008 English
F-10106S Medicaid Qualified Medicare Beneficiary (QMB) / Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approved Decision Notice (Spanish) PDF - Fillable 7/1/2008 Spanish
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice PDF - Fillable 7/1/2008 English
F-10108 Medicaid Manual Notice for Cost of Care Contribution PDF - Fillable 7/1/2008 English
F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions PDF - Print 7/1/2008 English
F-10109 Medicaid Remaining Deductible Update PDF - Print 11/1/2003 English
F-10110 Medicaid / BadgerCare Certification form Paper 1/1/1999 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification PDF - Fillable 7/1/2008 English
F-10111A Good Faith Medicaid Certification Instructions PDF - Print 8/1/2003 English
F-10112 Medicaid - Disability Application PDF - Fillable 7/1/2008 English
F-10112S Medicaid - Disability Application (Spanish) PDF - Fillable 10/1/2007 Spanish
F-10113 Information for Medicaid Disability Applicants PDF - Print 7/1/2008 English
F-10113S Information for Medicaid Disability Applicants (Spanish) PDF - Print 7/1/2008 Spanish
F-10114 Medicaid Disability Redetermination Report PDF - Fillable 7/1/2008 English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information PDF - Fillable 7/1/2008 English
F-10115S BadgerCare Plus / Medicaid Health Insurance Information (Spanish) PDF - Fillable 7/1/2008 Spanish
F-10119 Temporary Enrollment for BadgerCare Plus Family Planning Waiver Paper 7/1/2008 English
F-10119A Temporary Enrollment for BadgerCare Plus Family Planning Waiver Instructions PDF - Print 7/1/2008 English
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration PDF - Fillable 9/1/2008 English
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information PDF - Fillable 7/1/2008 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-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  PDF - Fillable 7/1/2008 English
F-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application PDF - Fillable 7/1/2008 English
F-10129H Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong PDF - Fillable 1/1/2003 Hmong
F-10129R Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian PDF - Fillable 1/1/2003 Russian
F-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish PDF - Fillable 1/1/2003 Spanish
F-10130 Medicaid Presumptive Disability PDF - Fillable 7/1/2008 English
F-10137 Medicaid Change Report PDF - Fillable 1/1/2008 English
F-10137H Medicaid Change Report - Hmong PDF - Fillable 2/1/2008 Hmong
F-10137R Medicaid Change Report - Russian PDF - Fillable 2/1/2008 Russian
F-10137S Medicaid Change Report - Spanish PDF - Fillable 2/1/2008 Spanish
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application PDF - Fillable 7/1/2008 English
F-10139 BadgerCare Plus Premium Information PDF - Fillable 7/1/2008 English
F-10139S BadgerCare Plus Premium Information (Spanish) PDF - Fillable 7/1/2008 Spanish
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-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request PDF - Fillable 7/1/2008 English
F-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF - Print 7/1/2008 English
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant PDF - Fillable 7/1/2008 English
F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice PDF - Fillable 7/1/2008 English
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-10154 Statement of Identity for Children Under 18 Years of Age PDF - Fillable 7/1/2008 English
F-10154H Statement of Identity for Children Under 18 Years of Age (Hmong) PDF - Fillable 7/1/2008 Hmong
F-10154R Statement of Identity for Children Under 18 Years of Age (Russian) PDF - Fillable 7/1/2008 Russian
F-10154S Statement of Identity for Children Under 18 Years of Age (Spanish) PDF - Fillable 7/1/2008 Spanish
F-10155 Employer Verification of Health Insurance Word - Fillable 4/1/2008 English
F-10161 Statement of Citizenship and / or Identity for Special Populations PDF - Fillable 2/1/2008 English
F-10162 Verification of Veterans Benefits PDF - Fillable 2/1/2008 English
F-10175 Statement of Identity for Persons in Institutional Care Facilities PDF - Print 2/1/2008 English
F-10182 BadgerCare Plus Application / Review Packet PDF - Fillable 10/1/2008 English
F-10182H BadgerCare Plus Application Packet (Hmong) PDF - Fillable 3/1/2008 Hmong
F-10182S BadgerCare Plus Application Packet (Spanish) PDF - Fillable 3/1/2008 Spanish
F-10183 BadgerCare Plus Change Report PDF - Fillable 1/1/2008 English
F-10183H BadgerCare Plus Change Report (Hmong) PDF - Fillable 1/1/2008 Hmong
F-10183S BadgerCare Plus Change Report (Spanish) PDF - Fillable 1/1/2008 Spanish
F-10186 Designation of a BadgerCare Plus Essential Person PDF - Fillable 3/1/2008 English
F-13023 Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  PDF - Fillable 12/1/2001 English
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  PDF - Fillable 12/1/2001 English
F-13025 BadgerCare Plus Premium Employer Wage Withholding PDF - Fillable 2/1/2008 English
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer PDF - Fillable 2/1/2008 English
F-13039 Estate Recovery Program (ERP) Disclosure PDF - Fillable 7/1/2005 English
F-13039A Estate Recovery Program (ERP) Disclosure Instructions PDF - Print 7/1/2005 English
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) PDF - Print 7/1/2008 English
F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) (Spanish) PDF - Print 7/1/2008 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-16021 Student Financial Report PDF - Fillable 4/1/2008 English
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-16031 Student Aid and Expense Worksheet PDF - Fillable 12/1/2001 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-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