Free Affidavit of lost Income or Disaster Related Cost, HCF 16106 - Wisconsin

STATE OR WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16106 (07/08)

APP

AFFIDAVIT OF LOST INCOME OR DISASTER-RELATED COSTS

This form must be completed if you are currently receiving FoodShare benefits and you are requesting a benefit supplement through the Disaster FoodShare Program. Name ­ Client (Last, First, MI)

Case Number

I certify under penalty of perjury that my household experienced either a loss of income or incurred disaster-related costs as a result of the flood that occurred in my county of residence during the period of June 5, 2008 through July 4, 2008.

SIGNATURE ­ Client

Date Signed

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