Free FoodShare Wisconsin Income Change Report, F-16066 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16066 (10/08)

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(Reduced Reporting Households)

FOODSHARE WISCONSIN INCOME CHANGE REPORT

(County Agency Address)

Personally identifiable information will be used only for the direct administration of FoodShare Wisconsin.
Your Name Case Number Worker Name

If your total monthly gross* household income is more than your income reporting limit, as shown below, report the change to your worker by the 10th of the next month. To report this change, fill out this report and mail it or take it to the office shown in the box above or contact your worker by telephone or in person. Some agencies may ask you to report changes to a change center, if the agency has one, instead of to your worker. For example: You start a new job on August 1st that pays more than what you are making now and there are three people getting FoodShare benefits in your case. If your total monthly gross* household income in August is more than your income reporting limit of $1,907, you must report the change to your FoodShare worker by September 10. You can also find the amount you are required to report on your latest notice of decision. *Total gross income means all income, job income or wages and unearned, received by everyone in your household before deductions such as taxes and withholdings.
2008 MONTHLY INCOME REPORTING LIMIT* Household Size Monthly Income Limit Household Size Monthly Income Limit 1 $1,127 6 $3,077 2 $1,517 7 $3,467 3 $1,907 8 $3,857 4 $2,297 9 $4,427 5 $2,687 10 $4,637 *These income amounts are based on the 2008federal poverty guidelines, which increase by a small amount every October. CHANGE IN INCOME JOB INCOME AND WAGES CHANGE Name Of Employed Person Employer

Rate Of Pay Per Hour $

Hours Per Week

How Often Paid

First Pay Date

Federal Law 7: CFR273.12(b)

FoodShare Wisconsin Income Change Report F-16066 (10/08)

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UNEARNED INCOME CHANGE (Examples of unearned income are Social Security benefits, pensions, W-2

payments, strike benefits, child support and alimony)
Name Of Person Receiving Unearned Income Date Income Changed

Source Of Income

New Monthly Amount $

INCOME CALCULATION Use this space to get the total household gross monthly income amount. Number Of Persons In Household Total Monthly Gross Unearned Income Total Monthly Gross Job Income and Wages Total Household Gross Monthly Income + = $ $ $

Month of Change

Total Household Gross Monthly Income From Above $

Do you expect that the changes reported on this form will remain the same next month? If no, explain. (If more space is needed, use the Other Changes section.)

Yes

No

You may continue to report other changes such as persons moving in or out of your household, or decreases in your monthly income; however, you are not required to do so. Should you choose to report these changes, contact your worker.
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FoodShare Wisconsin Income Change Report F-16066 (10/08)

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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. 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. If you intentionally fail to report any income increase that you are required to report or provide false information you may be fined, or have to pay back any FoodShare benefits you wrongfully received, or be prosecuted or all three. I understand there are penalties for hiding information or giving false information. 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. 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
(Include Area Code)

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FoodShare Wisconsin Income Change Report F-16066 (10/08)

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OTHER CHANGES

RESET
RETAIN COMPLETED FORM IN CASE FILE
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