Free FoodShare Nonfinancial Worksheet, F-16073 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16073 (08/08)

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FOODSHARE WISCONSIN NONFINANCIAL WORKSHEET
Social Security Number Benefit Month and Year

Primary Person's Name

Household Structure:

Family Group of each person = a. That person, b. That person's spouse, c. That person's non-marital co-parent (NMCP), d. All minors for whom any of the person's in a-c above are providing parental control, and e. Adult children under the age of 22, who are living with his or her birth, adoptive or stepparent. Name Pass Fail Name Pass Fail Name Pass Fail Name Pass Fail Name Pass Fail Name Pass Fail Name Pass Fail Name Pass Fail

Units

Initial Food Unit Individual Work Participation (Prior to 3/1/08) Sanctions (IPV/Drug Felon) Sanction Reason Begin date End date FoodShare Group

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out Pass Fail Mandatory Exempt Voluntary Yes No

In Out

In Out

In Out

In Out Standard Eligibility

In Out

In Out

In Out

In Out

Categorical Eligibility Mixed Categorical Eligibility

Number of persons in Food Unit Number of persons in FoodShare Group

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