Free Striker Evaluation, HCF 16023 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16023 (07/08)

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STRIKER EVALUATION

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 eligible for benefits. SSNs and personally identifiable information will be used only for the direct administration of FoodShare Wisconsin. See the application instructions or publication number PHC 16012 for more information on the use of your SSN. Complete this form if you are applying for FoodShare benefits and someone in your household is on strike. Do not write in the shaded areas. Attach separate sheets of paper if more room is needed.

OFFICE USE ONLY Case Name Case Number

SECTION I ­ APPLICANT / STRIKER INFORMATION Applicant Name (Last, First, MI) Address (Street, City, State, Zip Code) Name of Person on Strike Date Strike Began

Social Security Number

Striker's Social Security Number Name of Company Being Struck

SECTION II ­ HOUSEHOLD INFORMATION List the names of everyone who was in your household on the day before the strike began.

SECTION III ­ INCOME List the amount of earnings that the striker would have received if the strike had not occurred. How often were you paid? Rate of Pay $ $ $ Weekly Bi-weekly Monthly Bi-Monthly Total (Office Use Only) Converted Amount (Office Use Only)

Average hours per pay period

List the household's gross income for the month the strike began. Include Social Security payments, W-2 payments, Veterans benefits, Unemployment Insurance, Child Support received and earnings from all household members. Do not include earnings listed above. Amount Type of Income Date Person's Name

7 USC 2011-2036

STRIKER EVALUATION F-16023 (07/08)

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SECTION IV - ASSETS List the amount and type of all assets your household had on the day before the strike began. Types of assets include cash on hand, savings and/or checking accounts, savings bonds, property other than your home, etc. Amount Type of Asset Amount Type of Asset

SECTION V ­ CHILD CARE EXPENSE List the total amount your household paid for child or dependent care services the month the strike began. List only the amount you paid someone so you could work or look for work. $ SECTION VI - EXPENSES List the amount your household paid for shelter expenses the month in which the strike began. Rent Mortgage (including monthly property tax Water and insurance) Sewer Gas Heat Trash Removal Electricity Telephone

SECTION VII ­ MEDICAL EXPENSES Is anyone listed in section II one of the following (check yes or no for each)? · · · · · Sixty years of age or older Disabled Child of a Veteran Veteran with service connected disability Disabled surviving spouse of a veteran Disabled or blind and receiving Social Security Disability Yes Yes Yes Yes Yes No No No No No

If you answered "yes" above, list the amount and type of that person's medical expenses for the month the strike began. Amount Type Amount Type

SECTION IIX SIGNATURE My Signature shows that the answers on this form are correct and complete to the best of my knowledge. Date Signed SIGNATURE - Applicant

OFFICE USE ONLY Eligible Before Strike Yes No Gross Monthly Earnings of Striker before Strike $ Date

Agency Representative Name (please print)

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