Free Disaster FoodShare Wisconsin Assistance Application, HCF 16060 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16060 (07/08)

APP

DISASTER FOODSHARE WISCONSIN ASSISTANCE APPLICATION
INSTRUCTIONS: Complete this application and return it to the local county or tribal office. If more room is needed, use an additional sheet of paper. Do not write in shaded areas. You will be required to show proof of identity and that your household lived or someone in your household worked in the disaster area at the time of the disaster. You may be asked to provide proof of your costs. You can authorize someone outside your household to apply for emergency aid and to use your FoodShare benefits to assist your household. Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants FoodShare benefits but does not provide an SSN or apply for one will not be able to get benefits. SSNs and personally identifiable information will be used only for the direct administration of FoodShare Wisconsin. Your SSN permits a computer check of your information with government agencies such as the Internal Revenue Service (IRS), Social Security Administration (SSA) and the Department of Workforce Development, as well as the School Lunch Program. Social Security numbers are also used to check the identity of household members and to verify income from such sources as employers, banks and other parties. FOR OFFICE USE ONLY ­ DISASTER AUTHORIZATION PERIOD End date Application date Number

Begin date

SECTION I ­ APPLICANT INFORMATION Applicant name (Last, First, MI)

Verified

Authorized Representative

Permanent Home Address (Street, City, State, Zip Code) and Telephone Number

Verified

Temporary Address (Street, City, State, Zip Code) and Telephone Number

SECTION II ­ HOUSEHOLD SITUATION (Please check box) 1. Was your household living in the disaster area at the time of the disaster? If yes, answer the following questions. a. Did the disaster cause damage or destroy your home or self-employment property? b. Did the disaster cause your household to have additional cost? c. During the disaster clean up will your household need to buy food? d. Did the disaster delay, reduce or stop your household's income? e. Does your household have any cash or money in checking or savings accounts, which you cannot get because the bank is closed due to the disaster? 2. Do you currently get FoodShare or food stamp benefits? If yes, in what state and county? 3. If your food was destroyed in the disaster, what was the dollar amount of food that was lost? $

Yes

No

SECTION III ­ HOUSEHOLD MEMBERS List the members of your household, including yourself, who were living and eating with you at the time of the disaster. List each household member's Social Security Number (SSN), date of birth, source/type of income and the net amount of income. List any through . Note: If you other income your household members have received or expect to receive are temporarily staying with another household because of the disaster, do not list members of that household. Name (Last, First, MI) Social Security Number Date of Source / Type Amount Birth of Income $ $ $ $ $ $

DISASTER FOODSHARE ASSISTANCE APPLICATION F-16060 (07/08) Page 2

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Amount of each resource

SECTION IV ­ RESOURCES List all cash your household can get during this disaster. Include checking and savings accounts

SECTION V ­ DISASTER-RELATED COSTS For each item below, list the amount your household has paid or expects to pay, due to the disaster. Note: Do not include any costs that are not due to the disaster or were paid or will be paid by someone outside of your household. Type of Cost Amount Type of Cost Amount Type of Cost Amount Food destroyed Dependent care Funeral/medical $ $ $ Moving and storage Property protection Temporary shelter $ $ $ Other disaster-related cost $ Repair or replace items for home or self-employment property $

SECTION VI ­ ELIGIBILITY COMPUTATION FOR OFFICE USE ONLY 1. Total anticipated income 2. Total accessible cash 3. Add 1 and 2 4. Total disaster expenses 5. Total available funds (Subtract 4 from 3) $ $ $ $ $ 6. Maximum Income Limit 7. Eligible (5 is equal to or less than 6) 8. Ineligible (5 is greater than 6) $

SECTION VII ­ FOODSHARE WISCONSIN PENALTY Any member of your household who intentionally breaks any of the following rules can be barred from FoodShare Wisconsin for 12 months after the first violation, 24 months after the second violation or for the first violation involving a controlled substance and permanently for the third violation: · · · · Giving false information or hiding information to get or continue FoodShare benefits, Trading or selling FoodShare benefits, Using FoodShare benefits to buy non-food items, like alcohol or tobacco, or Using another person's FoodShare benefits, identification cards or other documentation.

Depending upon the value of misused benefits, the individual can also be fined up to $250,000, imprisoned up to 20 years, or both. A court can also bar an individual from the program for an additional 18 months. You will also be permanently disqualified if you are convicted of trafficking FoodShare benefits of $500 or more. You will be ineligible to participate for 10 years if you are found to have made a fraudulent statement or representation with respect to identity and residence in order to receive multiple benefits at the same time. Fleeing felons and probation/parole violators are ineligible for the program. The individual may also be subject to further prosecution under other applicable federal laws. Individuals who trade (buy or sell) FoodShare benefits for a controlled substance/illegal drug(s), will be barred from FoodShare Wisconsin for a period of two years for the first finding, and permanently for the second finding. Individuals who trade (buy or sell) FoodShare benefits for firearms, ammunition or explosives, will be barred from FoodShare Wisconsin permanently. SECTION VIII - CERTIFICATION AND SIGNATURE I understand the questions and statements on this application form. I understand the penalties for giving false information or breaking the rules. I certify, under penalty of perjury and false swearing, that all my answers are correct and complete to the best of my knowledge, including information provided about the citizenship status of each household member applying for benefits. I understand and agree to provide documents to prove what I have said. I understand that the local agency may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits. I understand that if I disagree with any action taken on my case, I have the right to request a fair hearing orally or in writing. USDA prohibits discrimination in the administration of its programs. To file a complaint, call (608) 266-9372 or 1-888-701-1251 (TTY). Two witnesses are required if signed with an X. SIGNATURE ­ Applicant / Authorized Representative WITNESS (Required if signed with an "X".) WITNESS (Required if signed with an "X".) Date Signed Date Signed Date Signed

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