Free State of Wisconsin - Wisconsin

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

APP
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

Reset 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.

FOODSHARE WISCONSIN REGISTRATION F-16019A (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 4

FOODSHARE WISCONSIN REGISTRATION F-16019A (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 REGISTRATION F-16019A (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.)