Free None - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16076 (07/08)

SMRF

FOODSHARE AND/OR CHILD CARE SIX-MONTH REPORT
TO AVOID A DELAY IN YOUR FOODSHARE AND/OR CHILD CARE BENEFITS, ANSWER ALL QUESTIONS, SIGN AND RETURN THIS FORM BY TO THE AGENCY LISTED BELOW. IF THIS FORM IS NOT COMPLETED AND RETURNED BY YOUR FOODSHARE AND/OR CHILD CARE BENEFITS WILL END.
CERTIFYING AGENCY: Case Number: Case Name: Worker Information Name: ID: Phone:

-------------- COMPLETE THIS FORM USING BLUE OR BLACK INK. PLEASE PRINT. ----------Please enclose all papers that provide proof of your answers including all pay stubs received in the last 30 days for all employed household members. For additional information regarding proof, refer to the instructions. Your worker will contact you if more information is needed to determine your eligibility for FoodShare and/or Child Care benefits.

SECTION 1 ­ ADDRESS / SHELTER EXPENSE INFORMATION
The address listed below is what we have on file for your household.

Have you moved to a different address?

Yes

No

If "No", you may skip to "Section 2 ­ Child Support Payments".

If "Yes", please complete the rest of this section. Enclose proof of your new address, shelter, and utility expenses.

What is your new address? If you are homeless, write "Homeless" in the space below. Street Apt Number

City

Zip Code

Telephone Number

If you do not have a telephone, what is a number where you can be reached? If you pay rent or lot rent, how much do you pay?
(If you live in subsidized housing, write in the amount of rent you must pay.)

$

per month

If you have a mortgage, how much do you pay? Property Taxes (if paid separately from your mortgage) Homeowners Insurance (if paid separately from your mortgage) What utility bills do you pay? (Check all that apply.) HEAT TELEPHONE ELECTRICITY COOKING GAS

$ $ $

per month per month per month

WATER or SEWER TRASH REMOVAL

SECTION 2 ­ CHILD SUPPORT PAYMENTS
Has any household member had a change in his or her legal obligation to pay child support? If "Yes", explain the change. Yes No

FoodShare and/or Child Care Six-Month Report F-16076 (07/08)

SMRF

SECTION 3 ­ HOUSEHOLD MEMBERS
Below are the names of all people we have as living in your household. Review the names and check "Yes", if they still live with you, or "No", if they do not. Yes No Yes No Yes No

Please complete the information below for new household members who were not pre-printed on the form. Use an additional sheet of paper if more room is needed or if more people have moved in with you. First Name Date of Birth (mm/dd/yy) Social Security Number What is the date this person moved in with you? (mm/dd/yy) Does this person purchase and prepare or share food with you? Is this person related to you? Yes No Yes No Last Name US Citizen Yes No Gender: Male Female

If "Yes", how is he or she related to you (for example, son, mother, brother, sister, etc.)?

SECTION 4 ­ HOUSEHOLD INCOME
A. Is anyone in your household employed? Yes No If "Yes", provide the following information for any person in your household who is working. Name Employer How Often Paid (weekly, biweekly, etc.) Date Started

REMINDER: ENCLOSE ALL PAY STUBS RECEIVED IN , FOR ALL EMPLOYED HOUSEHOLD MEMBERS. Pay stubs received in the last 30 days or an employer statement may also be used to verify current wages. B. This is the information we have about people in your household who are self-employed. Name Type of Business Average Counted Monthly Income

If this information is not correct, please explain the change here:__________________________________________________ _____________________________________________________________________________________________________ If anyone in your household has self-employment income not listed above, complete the information below. Name Type of Business Average Monthly Income _ C. Does anyone in your household receive other income? Yes No Date Self-Employment Began ____

If "Yes", list the source and monthly income amount below. Some examples of other income are payments from Child Support, Unemployment, Worker's Compensation or Social Security. Name Source of Income Monthly Amount

SECTION 5 ­ SIGNATURE
I certify that my answers on this form are correct and complete to the best of my knowledge. I understand that the information I provide on this form may result in a change or termination of my benefits. I also understand that if I intentionally give incorrect information it may result in a fine and/or imprisonment. SIGNATURE Date Signed 5th to:

To avoid a delay in your FoodShare and/or Child Care benefits, please return this form by

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