Free Wisconsin FoodShare Change Report, F-16006 - Wisconsin

WISCONSIN DEPARTMENT OF FAMILY SERVICES Division of Health Care Access and Accountability F-16006 (08/08)

CHG

FOODSHARE WISCONSIN CHANGE REPORT
(All household members are Elderly, Blind or Disabled)
If you get FoodShare benefits you must report, within ten days, any changes in your: · Address and shelter cost, · Income or employment status, or · Household (someone moves in or out of your home, if anyone gets married, becomes pregnant, or gives birth to a child). If such a change happens, you can: · Report it online at access.wi.gov, · Fill out this report and mail, fax or take it to the office shown in the box below Contact your worker by telephone or in person about any changes. If there not an address or telephone number in the box, you can get the address and telephone for your local agency at dhfs.wisconsin.gov/em/customerhelp, or by calling 1-800-362-3002 or 711 (TTY). If this report does not have enough room to for you to explain a change, write the information on a sheet of paper and attach it to this report. 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 able to get benefits. SSNs and personally identifiable information will be used only for the direct administration of FoodShare Wisconsin. If you intentionally fail to report any changes or give false information you may be fined, have to pay back any FoodShare benefits you wrongfully get, be prosecuted, or all of the above. You will need to give proof of any changes you report.

(County Agency Address)

Your Name

Case Number

Worker Name

CHANGE IN JOB INCOME AND WAGES New Job - 1
You must report and give proof of any new source of earned income. Examples of proof are check stubs, a letter from the employer or an Employer Verification of Earnings form (HCF 10146). Name of person with new job or income Rate of Pay per hour $ Hours per week

Employer
Federal Law 7CFR273.12(b)

How often paid

First pay date

FOODSHARE WISCONSIN CHANGE REPORT F-16006 (08/08)

CHG
Rate of Pay per hour $ Hours per week

New Job - 2
Name of person with new job or income

Employer

How often paid

First pay date

CHANGE IN OTHER INCOME
You must report any · New source of other income, · Change of more than $100 per month in child support income, or · Change of more than $50 per month in other types of unearned income such as Worker's Compensation, Unemployment Insurance, Social Security or Veterans benefits.

Name of person receiving unearned income

Source of income Monthly amount $

Income change

Yes

No

Date income changed

Name of person receiving unearned income

Source of income Monthly amount $

Income change

Yes

No

Date income changed

CHANGE IN ADDRESS AND RESULTING CHANGES IN SHELTER COSTS
If you move, you must report your new address, any increase or decrease in your rent or mortgage payment, or utility bills (gas, electric, water, etc.).

New address ­ Street City New telephone number (include area code) State Date of change Zip Code

CHANGE IN RENT
Are you in subsidized housing? Landlord name Landlord address ­ Street List utilities you must pay Yes No New monthly rent amount $ Landlord telephone number (include area code) City State Zip Code

Page 2

FOODSHARE WISCONSIN CHANGE REPORT F-16006 (08/08)

CHG
List utilities you must pay

CHANGE IN MORTGAGE
New monthly mortgage amount $ If not included in mortgage, list the monthly amount of Property tax $ Insurance $

CHANGE IN HOUSEHOLD
You must report if anyone: · Moves in or out of your household · Gets married · Becomes pregnant · Gives birth to a baby (include information about the person who gave birth and the newborn)

Name(s) Date of Birth Describe change Relationship to You

Social Security Number(s) (SSN) Date of Change

CHANGE IN CHILD SUPPORT PAYMENTS
You must report any changes in the legal obligation of any household member to pay child support.

Name of person court-ordered to pay child support Amount of monthly child support order $

Court Order Number Date of court order or date the order was changed

OTHER CHANGES?
Report any other changes which might affect your eligibility. Some examples of other changes include someone becoming disabled or recovering from a disability, someone dropping out of school, out of pocket medical expenses, etc. Include the date of the change.

Do you expect that the changes reported on this form will remain the same next month? If no, explain.

Yes

No

Page 3

FOODSHARE WISCONSIN CHANGE REPORT F-16006 (08/08)

CHG

FOODSHARE WISCONSIN PENALTY WARNING Any member of your household who intentionally breaks any of the following rules can be barred from FoodShare Wisconsin for 12 months after the first violation, 24 months after the second violation or for a first violation involving a controlled substance, and permanently for the third violation: · · · · Giving false information or hiding information to get or continue FoodShare benefits, Trading, selling or altering FoodShare benefits, Using FoodShare benefits to buy non-food items, like alcohol or tobacco, or Using another person's FoodShare benefits, identification cards or other documentation.

Depending upon the value of misused benefits, the individual can also be fined up to $250,000, imprisoned up to 20 years, or both. A court can also bar an individual from the program for an additional 18 months. You will also be permanently disqualified if you are convicted of trafficking FoodShare benefits of $500 or more. You will be ineligible to participate for 10 years if you are found to have made a fraudulent statement or representation with respect to identity and residence in order to receive multiple benefits at the same time. Fleeing felons and probation/parole violators are ineligible for the program. The individual may also be subject to further prosecution under other applicable federal laws. 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, that I will not receive any resulting increase in my FoodShare benefit. I understand there are penalties for hiding information or giving false information. I also understand I will have to pay back any benefits I receive because I do not fully report changes in my circumstances. I agree to provide proof of any changes, if asked to do so. My answers on this form are correct and complete to the best of my knowledge. Your SSN permits a computer check of your information with government agencies such as the Internal Revenue Service (IRS), Social Security Administration (SSA) and the Department of Workforce Development, as well as the School Lunch Program. Social Security numbers are also used to check the identity of household members and to verify income from such sources as employers, banks and other parties. NON-DISCRIMINATION If you have a disability and need to access this information in an alternate format, or need it translated to another language, please contact (608) 266-3356 (voice) or 1-888-701-1251 (TTY). For civil rights questions, call (608) 266-9372 (voice) or 1-888-701-1251 (TTY). Or in accordance with Federal law and U.S. Department of Agriculture policy, this institution 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 USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call 1-800-795-3272 (voice) or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer. SIGNATURE ­ Participant/Authorized Representative Date Signed Daytime Telephone Number

(
RETAIN COMPLETED FORM IN CASE FILE

)
Page 4

RESET