Free DRAFT FS Application Part I - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16019B (10/08)

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Registration

If you need an interpreter or other help completing this form, contact your local county or tribal agency for help. To find the telephone number and/or address of your local county or tribal agency go to dhs.wisconsin.gov/em/customerhelp or call Member Services at 1-800-362-3002. You may have another adult complete the application process for you. If your FoodShare benefits stopped within the last 30 days you may complete this form or contact your worker to find out if you can provide information to reopen your FoodShare without completing this form. You can start the application process for FoodShare by providing your name, address and signature online at access.wi.gov or on this page and returning it to your local agency. You can also apply online at access.wi.gov, by mail, in person or by telephone. To complete the application for FoodShare, you must have an interview, either by telephone or in person. You will be asked to provide proof of certain information such as identity, address and income. If you are enrolled in FoodShare, benefits will begin from the date your local agency receives your name, address and signature, which can be provided on this form or at access.wi.gov. Name ­ Applicant (Last, First, MI)

Social Security Number (Optional)

Date of Birth (Optional)

Telephone Number (Optional)

Address ­ Street

City

State

Zip Code

Signature (Applicant or Authorized Representative)

Date Signed

Your FoodShare application will be processed as soon as possible, but no later than 30 days from the date your registration form is received by the FoodShare office. If you need help right away or have an emergency, you may be able to get FoodShare within 7 days of providing your registration form if, your household: · Has $100 or less available in cash or in the bank and · Expects to receive less than $150 of income this month; or · Has rent/mortgage or utility costs that are more than your total gross monthly income, available cash or bank accounts for this month; or · Includes a migrant or seasonal farm worker whose income has stopped. Answer the following questions to be considered for faster service. Total gross income expected by your household this month (before taxes or other deductions) Total available assets (examples: cash, money in checking/savings accounts, CDs, stocks, IRAs, etc) Total rent or mortgage this month Total utilities this month (examples: gas, electric, water, sewer, trash removal) Did your household receive FoodShare benefits this month? Is anyone in your household a migrant or seasonal farm worker whose income has recently stopped and does not expect to receive more than $25 in income, in the next 10 days? $ $ $ $ Yes Yes No No

Tear Off and Submit This Page to Your Local FoodShare Office Keep the attached pages. If you do not understand any part of this form, ask your local agency to explain it.

Reset Registration

FOODSHARE WISCONSIN REGISTRATION F-16019B (10/08)

FoodShare Wisconsin Important Information
This FoodShare Wisconsin application is for FoodShare benefits only and is not an application for BadgerCare Plus, Medicaid, Child Care or Wisconsin Works (W-2). You can apply for BadgerCare Plus, Medicaid and FoodShare online at access.wi.gov or by contacting your local county or tribal agency. You must contact your local county or tribal agency to apply for Child Care or W-2. FoodShare is an entitlement. You do not have to apply for W-2 or other programs to be able to get FoodShare benefits. FoodShare benefits are available to help meet nutritional needs of low income households. A household is usually made up of people who live together and share food. The amount of FoodShare benefits a household gets is based on the household's size and income. FoodShare benefits are issued on a Wisconsin QUEST card which is used like a debit card at grocery stores that accept FoodShare. NON-DISCRIMINATION In accordance with Federal law and the U.S. Department of Agriculture policy, this institution (local county or tribal agency) is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs or disability. To file a complaint of discrimination write to the USDA or the Department of Health Services: USDA Director, Office of Civil Rights Room 326-W, Whitten Building 1400 Independence Avenue, S.W., Washington D.C. 20250-9410 Telephone: (800) 795-3272 (voice) or (202) 720-6382 (TTY) Department of Health Services (DHS) Affirmative Action and Civil Rights Compliance Office 1 W. Wilson, Room 555 Madison, WI 53707-7850 Telephone: Fax: (608) 266-9372 (Voice) or 1-888-701-1251 (TTY) (608) 267-2147

USDA is an equal opportunity provider and employer. FAIR HEARING You have the right to a fair hearing if you do not agree with any action taken regarding your application or your ongoing benefits. You may request a fair hearing by writing or calling: Department of Administration Division of Hearing and Appeals P.O. Box 7875 Madison, WI 53707-7875 (608) 266-3096 The Request for a Fair Hearing form may be downloaded at dhs.wisconsin.gov/em/customerhelp. You may also contact your local county or tribal office to ask for a Fair Hearing verbally or in writing. USE OF SOCIAL SECURITY NUMBERS/PERSONALLY IDENTIFIABLE INFORMATION Personally identifiable information, including Social Security Numbers (SSN) will be used only for the direct administration of FoodShare Wisconsin. Providing or applying for an SSN is voluntary; however anyone who does not provide their SSN or apply for one, will not be able to get FoodShare benefits. Anyone in the household who is not applying for FoodShare does not need to provide an SSN. Your SSN permits a computer check of your information from government agencies, such as the Internal Revenue Service (IRS), Social Security Administration, Department of Workforce Development or School Lunch Program. SSNs are also used to check identity and to verify income from sources such as employers. AUTHORIZED REPRESENTATIVE You have the right to have another person apply for FoodShare benefits for you. This person will act as an "authorized representative". If you want to have an authorized representative, complete the Authorization of Representative form (F10126). To get this form go to dhs.wisconsin.gov/em/customerhelp or ask the local agency. If an authorized representative provides wrong information which is used to determine your FoodShare benefits, you will be responsible for any mistakes. IMMIGRATION STATUS To be able to get FoodShare, you must be a United States citizen or have a qualifying immigration status with the United States Citizenship and Immigration Services (USCIS). Immigration status of all people applying for FoodShare will be verified with USCIS and may affect FoodShare enrollment and benefit amount. Immigration status will NOT be verified with USCIS for any person who is not applying for FoodShare or who indicate they do not have qualifying immigration status with the USCIS. However, income from those individuals may affect FoodShare enrollment or benefit amount. Page 2 of 12

FOODSHARE WISCONSIN REGISTRATION F-16019B (10/08) WORK REGISTRATION Every one in your FoodShare group must be registered for work, unless otherwise exempt. Those who do not have to register for work include: · · · · · · · A parent or other household member who is responsible for the care of a dependent child who is less than 6 years old, or for a disabled person of any age; A person younger than 16 years of age, or 60 years of age or older; People in drug addiction or alcohol treatment programs; People who are already working at least 30 hours per week (or are getting weekly earnings which equal 30 times the federal minimum hourly wage); People who are getting, or have applied for, Unemployment Insurance; Students enrolled in a recognized school, training program, or institution of higher learning; or People who are physically or mentally unfit for employment as determined by the local agency.

Although registration for work is required, taking part in a work program is voluntary. Your benefits will not change if you choose not to take part. You will get more information about the FoodShare Employment and Training Program if you are enrolled in FoodShare. COLLECTION OF INFORMATION The collection of information on the application, including the Social Security Number of each household member applying, is authorized under the Food Stamp Act of 1977, as amended, 7 U.S.C. 2011-2036 to determine if your household is able to take part in FoodShare Wisconsin. Information will be verified through computer matching programs and will also be used to monitor compliance with FoodShare program rules and program management. COMPUTER CHECK Information on your application will be subject to verification through the state income and eligibility verification system. If you work, job income and wages you report will be checked by computer against wages your employer reports to the Department of Workforce Development. The IRS, Social Security Administration and Unemployment Insurance Division are also contacted about income and assets you may have. Information from these agencies may affect your household's enrollment and/or benefit amount. If any information you give is found to be incorrect, you may be denied FoodShare benefits and/or be subject to criminal prosecution for knowingly providing false information. You must repay any benefits you get, if you gave false information. If a FoodShare claim is made against your household, information on the application, including all Social Security Numbers, may be referred to federal and state agencies, as well as private collection agencies for claims collection action. FOODSHARE PENALTY WARNING Any member of your household who intentionally breaks any of the following rules can be barred from FoodShare 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 to get FoodShare benefits, · Trading or selling FoodShare benefits, · Using FoodShare benefits to buy nonfood items, like alcohol or tobacco, · Using another person's FoodShare benefits, identification cards or other documentation. Depending on the value of the misused benefits, you can also be fined up to $250,000, imprisoned up to 20 years or both. A court can also bar you from FoodShare Wisconsin for an additional 18 months. You will be permanently disqualified if you are convicted of trafficking FoodShare benefits of $500 or more. You will not be able to take part in FoodShare Wisconsin for 10 years if you are found to have made a fraudulent statement or representation with respect to identity and residence to receive multiple benefits at the same time. Fleeing felons and probation/parole violators are not able to take part in FoodShare Wisconsin. You may also be subject to further prosecution under other applicable federal laws. If you trade (buy or sell) FoodShare benefits for a controlled substance/illegal drugs, you will be barred from the FoodShare program for a period of 2 years for the first finding and permanently for the second finding. If you trade (buy or sell) firearms, ammunition or explosives, you will be barred from FoodShare Wisconsin permanently.

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FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

PROOF NEEDED
Enrollment in FoodShare cannot be determined until you provide proof of certain answers. The list below shows what is proof is needed and items you can use. If you have an appointment at the agency, please bring as many items on the list as you can to your interview. If your appointment is by phone, you will be sent a list of the items you will need after your appointment. If you are not able to get the items you need, tell us what items you are not able to get and we can help you. You may be asked to give proof of items not listed below. If so, your worker will send you a list of other proof that is needed. Proof Needed Identity · · · · · · Suggested Ways to Give Proof Drivers License Birth Certificate Passport or US Citizen Card Paycheck Employee ID Hospital Record.

Earned Income

· All check stubs received in the last 30 days · A signed statement from employer that includes gross earnings and pay dates expected in the next 30 days · Employer Verification of Earnings form · Award letter · Copy of last check

Unearned Income Unemployment Insurance Disability Insurance, Social Security, Retirement, Veteran's Benefits, Military Allotments Monthly Rent or House Payment (Required to get a credit.)

· Current rent receipt with landlord's name and phone number on it · Lease or mortgage papers · Real estate property tax statement · Homeowner's insurance statement · Current utility and phone bills · Statement from utility company · Signed statement from the child care provider · Receipts · Bills · Court order papers or other record of payment · Payment record from other state
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Monthly Utility Expenses (Required to get a credit.) Child Care Expenses (Required to get a credit.) Child Support received or paid in a state other than Wisconsin (Required to get a credit.)

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APPLICATION

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

This application is for FoodShare benefits only. This is not an application for Medicaid, BadgerCare Plus, Child Care or W-2. If you are interested in applying for these assistance programs you must contact your local agency. These programs provide persons or families help with the cost of health care, child care or finding a job as part of W-2. How to use this form 1. Do not write in the shaded sections. 2. Print clearly. Use blue or black ink. 3. Fill out the application completely. 4. If you need help filling out this application, contact your local agency and ask for help. If you have a disability and need to access this application in an alternate format, or need it translated to another language, please contact (608) 266-3356 (voice) or 1-888-701-1251 (TTY). These translation services are free of charge. 5. To complete the application process for FoodShare benefits you will be required to have an interview with a FoodShare or Social Security Administration worker.
SECTION 1 ­ LOCAL COUNTY OR TRIBAL AGENCY INFORMATION

(Agency Use Only) Agency Name Date Received

Agency Address (Street, City, State, Zip Code)

Case Name

Case Number

SECTION 2 - PERSON COMPLETING APPLICATION

If you need help completing this application, you can have another person help you or appoint an Authorized Representative to represent you in the application process. Then, have that person answer the following questions. If not, skip to Section 3. Name of person completing application if other than the applicant (Last, First, MI) Relationship to Applicant Do you live in the household? Yes No

SECTION 3 - APPLICANT INFORMATION

If you are completing this application for someone else, answer the rest of the questions as if you were that person. Applicant Name (Last, First, MI) Check the language in which you want FoodShare notices printed. English Spanish Residence Address (Street) Mailing Address ­ If different from your residence (Street/PO Box, City, State, Zip Code) (City) (State)

Primary language spoken in your home:

(Zip Code)

Telephone Number (Including area code)

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Section 4 - Household Information

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

If more room is needed, use a blank sheet of paper or the "Notes" section of this application to answer these questions.
List the names of all persons living in your household. Is this person applying for FoodShare benefits?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Social Security Number (Those Applying Only)

Date of Birth (MM/DD/YY)

Gender M - Male F - Female

Marital Status

Name (Last, First, MI)

U.S. Citizen (Only for those applying )
Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Race or Ethnicity (Optional)

Relationship to Applicant

Do you share food with this person?

Do you provide care for this person?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No

M F M F M F M F M F M F M F

Married Single Divorced Married Single Divorced Married Single Divorced Married Single Divorced Married Single Divorced Married Single Divorced Married Single Divorced

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Section 5 - Student Information

If more room is needed, use a blank sheet of paper or the "Notes" section of this application to answer these questions.
Is there anyone 18 ­ 49 years of age attending school? Yes No Section 6 If no, go to Is the student caring for a child under 6 years of age? Yes No Is the student a single parent caring for a child under 12 years of age and attending school full time? Yes No Is the student unable to work due to a temporary or permanent disability? Yes No Yes No Name of Student (Last, First, MI) Name of School Enrollment Part time Full time

Is the student employed at least 20 hours per week? Yes No Is the student caring for a child 6-12 years of age where adequate daycare is not available? Yes No Is the student participating in a federal or state funded work-study program? Yes No

Is the student attending school due to placement through Workforce Investment Act (WIA), Wisconsin Works (W-2) or FoodShare Employment and Training (FSET)?

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Section 6 - Non-Financial Information

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

If more room is needed, use a blank sheet of paper or the "Notes" section of this application to answer these questions.
Name of Pregnant Woman (Last, First, MI) Is anyone in the household pregnant? Has anyone been found totally disabled by the Social Security Administration (SSA), Veteran's Administration (VA), or Railroad Retirement Board? Yes No Name (Last, First, MI) Yes No Date of Disability Determination (mm/dd/yy) Estimated Due Date (mm/dd/yy)

Name (Last, First, MI) Has anyone been convicted of a drug felony? Is anyone a fleeing felon or in violation of probation/parole? Yes No Name (Last, First, MI) Yes No

Date of Conviction (mm/dd/yy)

Section 7 - Absent Parent Information

If more room is needed, use a blank sheet of paper or the "Notes" section of this application to answer these questions.
Do any children have a natural or adoptive mother or father who is not living at home? Name of Absent Parent (Last, First, MI) Social Security Number Yes No Date of Birth Name(s) of Child(ren) Relationship to Child Mother Father Court Order of Divorce / Paternity Case Number County State

Reason for Parent's Absence

Date Parent Left Household

Date Last Contact With Parent

Name of Absent Parent (Last, First, MI)

Social Security Number

Date of Birth

Name(s) of Child(ren)

Reason for Parent's Absence

Date Parent Left Household

Date Last Contact With Parent

Relationship to Child Mother Father Court Order of Divorce / Paternity Case Number County State

Name of Absent Parent (Last, First, MI)

Social Security Number

Date of Birth

Name(s) of Child(ren)

Reason for Parent's Absence

Date Parent Left Household

Date Last Contact With Parent

Relationship to Child Mother Father Court Order of Divorce / Paternity Case Number County State

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Section 8 - Assets
Asset

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

information is only needed for persons applying for emergency benefits List all assets owned by the applicant(s). Include assets owned jointly with anyone else. Do not include the value of personal household belongings, unless they have an unusually high value. Type Name of Owner(s) Current Description (such as Bank/Financial Name of Owner(s) Current Description (such as Bank/Financial Value Institution Name, Account Number) Value Institution Name, Account Number) Cash $ Checking Account Savings Account $ Other (for example: stocks, bonds, certificates of deposit, IRA) $ $ $ $

$

$

Section 9 - Employment FoodShare benefit eligibility will be based on total household income. Yes No Is any household member working (including self-employment)? If "Yes", answer questions below for each household member who is working. Name of Person Working Employer Name and Address Is anyone listed below a migrant worker? Date employment began? Pay period (weekly, biweekly, monthly) Yes No $ per Hour Gross Earnings per Pay Period

Number of Hours in Pay Period

Section 10 - Loss of Employment Has anyone recently ended employment? Name of Person Yes No If "Yes", complete the rest of Section 10. Employer Name and Address Date employment ended? (mm/dd/ccyy)

Reason Employment Ended? (quit, fired, laid off, moved)

Has this person applied for unemployment insurance?

Yes

No

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Section 11 - Unearned Income

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

Yes No If you answered "Yes", complete the section below for each income type. If more room is needed, use a blank Does anyone in your household receive unearned income? sheet of paper or the "Notes" section of this application to answer these questions. Type of Income Name Gross Monthly Type of Income Name Gross Monthly Amount Amount Social Security Supplemental Security Income (SSI) Alimony / Child Support Workers / Unemployment Compensation Section 12 ­ Expenses If more room is needed, use a blank sheet of paper or the "Notes" section of this application to answer these questions. Child Care - Does anyone pay for Who pays for child / adult care? Who is paid? Who is it for? child or adult care so they can work, Yes look for work, go to school or receive No training? Child Support ­ Is anyone courtordered to pay child support? Who pays the child support? Yes No Who is the expense for? Yes No Who pays the expense? Yes No Yes No Yes No Who pays the expense? What is the expense? Amount $ How often paid? (weekly, biweekly, monthly) What is the expense? What are the expenses? Who receives the child support payments? Amount $ How often paid? (weekly, biweekly, monthly) Yes No Yes No Yes No Yes No $ Disability / Sick Pay Yes No Yes No Yes No Yes No $

$

Interest / Dividends

$

$

Veterans Benefits

$

$

Other income (describe)

$

Amount $ Amount $

How often paid? (weekly, biweekly, monthly) How often paid? (weekly, biweekly, monthly) How often paid? (weekly, biweekly, monthly)

Medical Expenses ­ Does any elderly or disabled household member have out-of-pocket medical expenses? Shelter Costs - Does anyone in the household have shelter costs? (rent, mortgage, property taxes, etc.) Do you receive housing assistance? (Section 8 or other subsidized public housing) Utility Expenses ­ Does anyone in the household have utility expenses? (heat, electricity, water, phone, etc.)
Have you received heating assistance at this address?

Amount $

Yes No

Date heating assistance received? (mm/dd/yy)

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Section 13 - Rights and Responsibilities Read and initial each statement below:

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

___ Fair Hearings: I understand I have the right to file a fair hearing request to appeal any action taken concerning my application or ongoing benefits if I do not agree with that action. I understand I can ask for a Fair Hearing by writing to: Department of Administration, Division of Hearings & Appeals, Box 7875 Madison WI 53708-7875 or by calling (608) 266-3096. I may also contact the agency office where I applied and ask for a Fair Hearing verbally or in writing. I understand I can refer to the FoodShare Wisconsin Enrollment and Benefits handbook (P-16012) for more information. ___ Rights and Responsibilities: I have received the "Important Information" section of the FoodShare Wisconsin Application that includes my rights and responsibilities. ___ Reporting Changes: I Understand that failure to report any changes which result in incorrect benefits will mean recovery of any amounts overpaid and could also lead to prosecution for fraud, a felony. ___ Expenses: I understand that expenses I report such as shelter, utility, child care, child support or medical costs may affect the level of FoodShare benefits my household receives. I understand that failure to report or verify an expense means that I do not want to receive a deduction for this expense. ___ Income Reduction: I understand that I am not required to report a reduction or loss of income; however, I may be entitled to a higher FoodShare benefit if I do. I understand that as long as I do not report a reduction in my household's monthly income or the loss of any household income, I will not receive any resulting increase in my FoodShare benefit. ___ Immigration Status: I understand that I and all other persons living in my household and who apply for aid must be citizens or in a satisfactory immigration status in order to receive assistance. I understand that the immigration status of any person in my household applying for benefits will be verified with the United States Citizenship and Immigration Services (USCIS); this information provided by USCIS may affect my household's eligibility and amount of benefits. I understand that my status will NOT be verified with USCIS if I am not requesting assistance for myself or if I state that I am an immigrant without satisfactory immigration status. ___ Any person, including any financial institution, credit reporting agency, employer or educational institution, is authorized to release this information, according to Wisconsin Statute §49.22 (2) (2m): "The department may request from any person any information it determines appropriate and necessary for the administration of programs carrying out the purposes of 7USC 2011 to 2029. Any person in this state shall provide this information within seven (7) days after receiving a request under this subsection." ___ 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.

________________________________________________________________________________ SIGNATURE ­ Applicant or Authorized Representative

__________________________________________ Date Signed
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NOTES

FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

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FOODSHARE WISCONSIN APPLICATION F-16019B (10/08)

NOTES

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