Free Disaster FoodShare Notice, HCF 16105 - Wisconsin


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State: Wisconsin
Category: Health Care
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http://dhs.wisconsin.gov/forms/F1/F16105.pdf

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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16105 (07/08)

NOD
Case Number City Date State Zip Code

DISASTER FOODSHARE NOTICE
Applicant / Member Name Address Street

See Explanation of Action section for more details. Positive Notice



Your application for Disaster FoodShare benefits has been approved. You will soon receive Disaster FoodShare benefits on your QUEST card in the amount of $ .



If you have never had a QUEST card, one will be mailed to you or you may pick it up at the local agency the day after your application is processed. If you already have a QUEST card your benefits will be added to that card and available the day after your application is processed. If you no longer have your QUEST card a replacement card can be issued to you by the local agency or by calling QUEST Customer Service 1-877-415-5164 (voice) or 711 (TTY).

Negative Notice



Your application for Disaster FoodShare benefits has been denied. Your application for Disaster FoodShare benefits has been cancelled because you have withdrawn the application. We have not made a decision on your Disaster FoodShare application because .

Explanation of Action(s). Please include income and expenses used in the eligibility determination.

If you do not agree with your FoodShare benefits, you can request a fair hearing. Please see the enclosed for information about fair hearings. If you have questions, please contact Local county/tribal agency

RESET FORM

7 CFR 280

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16105 (07/08)

YOUR RIGHTS AND RESPONSIBILITIES FOR DISASTER FOODSHARE
YOU HAVE THE RIGHT TO A WRITTEN NOTICE from this agency before any action is taken to stop or reduce your FoodShare benefits. For most actions, a notice will be mailed to you at least 10 days before the action is taken. . YOU MAY REQUEST A FAIR HEARING FOR FOODSHARE BENEFITS if you disagree with any agency's action including your FoodShare benefit amount. You may request a fair hearing in writing or in person with the agency listed on the front of this notice. You may also request a fair hearing by writing to the Department of Administration, Division of Hearings and Appeals, PO Box 7875, Madison, WI 53707-7875 or by calling 1-608266-3096. Your request must be received within 90 days of the action's effective date for FoodShare Wisconsin, or at anytime while you are getting benefits, if you do not agree with the benefit amount. You may represent yourself or be represented at the hearing or conference by an attorney, friend or anyone else you choose. Free legal help may be available through Wisconsin Judicare, Inc. or Legal Action of Wisconsin, Inc (LAW). To find the office closest to you, contact: Judicare at (715) 842-1681 or www.judicare.org/, or LAW at 1-888-278-0633 or www.badgerlaw.net/index_html.

If you fail to appear, or your representative fails to appear at the hearing without good cause, your appeal is considered abandoned and will be dismissed.

COMPUTER CHECK: If you work, the wages you report are checked by the computer against the wages your employer reports to the Department of Workforce Development. The Internal Revenue Service, Social Security Administration, Unemployment Insurance Division and Department of Transportation may also be contacted about income and assets you may have.

IF YOU RECEIVE BENEFITS OR SERVICES, you must follow these rules: DO NOT give false information or hide information to get or continue to get benefits. DO NOT trade or sell FoodShare benefits. DO NOT alter cards to get benefits you are not entitled to receive. DO NOT use FoodShare benefits to buy ineligible items, like alcohol or tobacco. DO NOT use someone else's FoodShare benefits. Anyone in your household who intentionally breaks any FoodShare Wisconsin rule can be barred from receiving FoodShare Wisconsin benefits for 12 months after the first violation, 24 months after the second violation and permanently after the third violation. The individual can also be fined up to $250,000, imprisoned up to 20 years or both. A court can also bar a person from receiving FoodShare Wisconsin benefits for an additional 18 months. The person may also be subject to further prosecution under the applicable laws.

RE: Federal Regulations Wisconsin Statutes

7 CFR 273 49.79