Free None - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Heath Care Access and Accountability F-16004 (07/08)

EBT

DESIGNATION OF AUTHORIZED BUYER / ALTERNATE PAYEE FOR FOODSHARE BENEFITS
Social Security Numbers and personally identifiable information will be used only for the direct administration of FoodShare Wisconsin. You can choose an Authorized Buyer to help you use your FoodShare benefits. In addition to you receiving a card, the authorized buyer will receive a QUEST card with his/her name on it, and will have access to your FoodShare account to purchase food for your household. or You can choose an Alternate Payee to use FoodShare benefits on your behalf. The alternate payee will receive a QUEST card with his/her name on it. You will not receive a QUEST card. or You can cancel access to your QUEST card account you granted to others at any time. To cancel access to your account, contact your worker or call the QUEST Customer Service Help Line number at 1-877-415-5164. Case Name Case Number Worker Name

By checking the box(es) below I certify that: I want designated as my Authorized Buyer to access my FoodShare account to buy my food. I understand we will both be issued a card. My authorized buyer's QUEST card should be mailed to: . Street I want City State Zip Code removed as an Authorized Buyer from my case.

I want designated as my Alternate Payee to access my FoodShare account to buy my food. I understand only my Alternate Payee will be issued a card. My alternate payee's QUEST card should be mailed to: . Street I want I understand: Any FoodShare account transaction made by myself, an Authorized Buyer, Alternate Payee or by any other person to whom I voluntarily give my QUEST card and PIN is considered authorized and the benefits will not be replaced. Your signature must be witnessed. Two witness signatures are required if you sign with an X. City State Zip Code removed as an Alternate Payee from my case.

SIGNATURE - Primary Cardholder or Other Payee SIGNATURE ­ Witness 1 (Required) SIGNATURE ­ Witness 2 (Required if signed with an X.)

Date Signed Date Signed Date Signed

NOTE: You have the right to have another person represent you and act on your behalf to complete the application / review process. This person will act as your "authorized representative". If you wish to authorize someone to act on your behalf, complete the "Medicaid /BadgerCare Plus/FoodShare Authorization of Participant's Representative" form (HCF 10126). To get this form, contact your worker or visit dhfs.wisconsin.gov/forms/DHCF/HCF10126.pdf. For Case Worker Use Only New Alternate Payee Remove Authorized Buyer Date Signed

New Authorized Buyer SIGNATURE ­ IM Worker

Remove Alternate Payee

DISTRIBUTION:

Case File ­ Original

Member ­ Copy

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