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Eligibility Management (Income Maintenance) Home >> IM Forms

All Income Maintenance (IM) Forms
Sorted by Form Title

Last Revised: July 14, 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 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
Authorization to Disclose Information to Disability Determination Bureau (DDB) F-14014 PDF - Print 7/1/2008 English
Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) (Spanish) F-14014AS PDF - Print 7/1/2008 Spanish
BadgerCare Plus / Medicaid Health Insurance Information F-10115 PDF - Fillable 2/1/2008 English
BadgerCare Plus / Medicaid Health Insurance Information (Spanish) F-10115S PDF - Fillable 12/1/2004 Spanish
BadgerCare Plus Application Packet F-10182 PDF - Fillable 3/1/2008 English
BadgerCare Plus Application Packet (Hmong) F-10182H PDF - Fillable 3/1/2008 Hmong
BadgerCare Plus Application Packet (Spanish) F-10182S PDF - Fillable 3/1/2008 Spanish
BadgerCare Plus Change Report F-10183 PDF - Fillable 1/1/2008 English
BadgerCare Plus Change Report (Hmong) F-10183H PDF - Fillable 1/1/2008 Hmong
BadgerCare Plus Change Report (Spanish) F-10183S PDF - Fillable 1/1/2008 Spanish
BadgerCare Plus Premium Employer Wage Withholding F-13025 PDF - Fillable 2/1/2008 English
BadgerCare Plus Premium Information F-10139 PDF - Fillable 4/1/2008 English
BadgerCare Plus Premium Information (Spanish) F-10139S PDF - Fillable 4/1/2008 Spanish
BadgerCare Plus Premium Member / Employer Electronic Funds Transfer F-13026 PDF - Fillable 2/1/2008 English
BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 PDF - Fillable 1/1/2008 English
Community Spouse Asset Share Notice F-10096 PDF - Fillable 4/1/2008 English
Designation of a BadgerCare Plus Essential Person F-10186 PDF - Fillable 3/1/2008 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
Employer Verification of Health Insurance F-10155 Word - Fillable 4/1/2008 English
Employment Verification of Earnings F-10146 Word - Fillable 12/1/2007 English
Estate Recovery Program (ERP) Disclosure F-13039 PDF - Fillable 7/1/2005 English
Estate Recovery Program (ERP) Disclosure Instructions F-13039A PDF - Print 7/1/2005 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 10/1/2008 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 Worksheet F-16033 PDF - Fillable 10/1/2008 English
Good Faith Medicaid / BadgerCare Plus Certification F-10111 PDF - Fillable 2/1/2008 English
Good Faith Medicaid Certification Instructions F-10111A PDF - Print 8/1/2003 English
Income Maintenance Quality Assurance (IMQA) Web Request F-16083 PDF - Fillable 4/1/2005 English
Information for Medicaid Disability Applicants F-10113 PDF - Print 2/1/2008 English
Information for Medicaid Disability Applicants (Spanish) F-10113S PDF - Print 2/1/2008 Spanish
Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant F-10142 PDF - Fillable 10/1/2005 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 - Disability Application F-10112 PDF - Fillable 10/1/2007 English
Medicaid - Disability Application (Spanish) F-10112S PDF - Fillable 10/1/2007 Spanish
Medicaid / BadgerCare Certification form F-10110 Paper 1/1/1999 English
Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S PDF - Fillable 3/1/2005 Spanish
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
Medicaid / BadgerCare Plus and Family Planning Services Registration Application F-10129 PDF - Fillable 2/1/2008 English
Medicaid / BadgerCare Plus Overpayment Notice F-10093 PDF - Fillable 2/1/2008 English
Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse F-10095 PDF - Fillable 1/1/2008 English
Medicaid Change Report F-10137 PDF - Fillable 1/1/2008 English
Medicaid Change Report - Hmong F-10137H PDF - Fillable 2/1/2008 Hmong
Medicaid Change Report - Russian F-10137R PDF - Fillable 2/1/2008 Russian
Medicaid Change Report - Spanish F-10137S PDF - Fillable 2/1/2008 Spanish
Medicaid Disability Redetermination Report F-10114 PDF - Fillable 1/1/2004 English
Medicaid Income Allocation Notice F-10097 PDF - Fillable 2/1/2008 English
Medicaid Manual Notice for Cost of Care Contribution F-10108 PDF - Fillable 4/1/2008 English
Medicaid Manual Notice for Cost of Care Contribution Instructions F-10108A PDF - Print 4/1/2008 English
Medicaid Member Asset Allocation Notice F-10098 PDF - Fillable 1/1/2008 English
Medicaid Presumptive Disability F-10130 PDF - Fillable 4/1/2008 English
Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  F-10127 PDF - Fillable 3/1/2008 English
Medicaid Purchase Plan (MAPP) Independence Account Registration F-10121 PDF - Fillable 9/1/2008 English
Medicaid Purchase Plan (MAPP) Member / Premium Information F-10122 PDF - Print 3/1/2008 English
Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  F-13024 PDF - Fillable 12/1/2001 English
Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  F-13023 PDF - Fillable 12/1/2001 English
Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice F-10106 PDF - Fillable 1/1/2008 English
Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice F-10107 PDF - Fillable 1/1/2008 English
Medicaid Remaining Deductible Update F-10109 PDF - Print 11/1/2003 English
Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong F-10129H PDF - Fillable 1/1/2003 Hmong
Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian F-10129R PDF - Fillable 1/1/2003 Russian
Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish F-10129S PDF - Fillable 1/1/2003 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
Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility F-10099 PDF - Fillable 2/1/2008 English
Positive Notice F-16015 PDF - Fillable 1/1/2008 English
Positive Notice - Spanish F-16015S PDF - Fillable 4/1/2006 Spanish
Presumptive Eligibility for the Family Planning Waiver Program (FPWP) F-10119 Paper 6/1/2006 English
Presumptive Eligibility for the Family Planning Waiver Program (FPWP) Instructions F-10119A PDF - Print 6/1/2006 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 - 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
SeniorCare Application F-10076 PDF - Print 7/1/2003 English
SeniorCare Authorization of Representative F-10080 PDF - Fillable 12/1/2004 English
SeniorCare Instructions for Application Form F-10076A PDF - Print 10/1/2005 English
SeniorCare Instructions for Application Form - Hmong F-10076AH PDF - Print 10/1/2005 Hmong
SeniorCare Instructions for Application Form - Russian F-10076AR PDF - Print 10/1/2005 Russian
SeniorCare Instructions for Application Form - Spanish F-10076AS PDF - Print 10/1/2005 Spanish
Social Security Number Referral F-16022 PDF - Fillable 1/1/2008 English
Statement of Citizenship and / or Identity for Special Populations F-10161 PDF - Fillable 2/1/2008 English
Statement of Identity for Children Under 18 Years of Age F-10154 PDF - Fillable 2/1/2008 English
Statement of Identity for Children Under 18 Years of Age (Hmong) F-10154H PDF - Fillable 2/1/2008 Hmong
Statement of Identity for Children Under 18 Years of Age (Russian) F-10154R PDF - Fillable 2/1/2008 Russian
Statement of Identity for Children Under 18 Years of Age (Spanish) F-10154S PDF - Fillable 2/1/2008 Spanish
Statement of Identity for Persons in Institutional Care Facilities F-10175 PDF - Print 2/1/2008 English
Striker Evaluation F-16023 PDF - Fillable 10/1/2004 English
Student Aid and Expense Worksheet F-16031 PDF - Fillable 12/1/2001 English
Student Financial Report F-16021 PDF - Fillable 4/1/2008 English
Verification of Veterans Benefits F-10162 PDF - Fillable 2/1/2008 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 Funeral and Cemetery Aids Program Reimbursement Notice F-10143 PDF - Fillable 2/1/2008 English
Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 PDF - Fillable 3/1/2008 English
Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A PDF - Print 3/1/2008 English
Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet F-10101 PDF - Fillable 8/1/2008 English
Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Hmong) F-10101H PDF - Fillable 8/1/2007 Hmong
Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Russian) F-10101R PDF - Fillable 8/1/2007 Russian
Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Spanish) F-10101S PDF - Fillable 8/1/2007 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
Wisconsin Well Woman Medicaid Determination F-10075 PDF - Fillable 7/1/2006 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 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