Free FoodShare Wisconsin Overissuance Worksheet, HCF 16030 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16030 (10/08)

NOD

FOODSHARE WISCONSIN UNDER/OVERISSUANCE WORKSHEET
Case Name Agency Case Number Supportive Services Planner Claim Number Date

Income Month / Year Payment Month / Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Group Size Earned Income Unearned Income Total Gross Income (2 plus 3) Gross Income Limit Excess Medical Expense Subtract 6 from 4 Earned Income Deduction * Subtract 8 from 7 Standard Deduction Subtract 10 from 9 Dependent Care Expense Shelter Deduction Child Support Paid Total Deductions, add 12, 13 and 14 Total Net Income (11 minus 15) Net Income Limit Allotment (Table 8.1.8 from FSH) Prior Monthly Recoupment Withheld Correct Allotment (18 minus 19) Actual Issuance (Note: If 18=0, add 19 to this figure before entering) Underissuance (20 minus 21) FoodShare Overissuance (22 minus 20)
equals the

Total all the amounts on line 23 $ , minus all the amounts on line 22 $ amount that must be repaid for this FoodShare overissuance $ .

*When an overissuance occurs because the group intentionally failed to report earned income, do not apply the earned income deduction. Distribution: Member ­ original Case file - copy

RESET FORM