Free FoodShare Wisconsin Repayment Agreement, HCF 16029 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16029 (07/08)

OP
Case Number Date Amount Due $

FOODSHARE WISCONSIN REPAYMENT AGREEMENT
Personally identifiable information will be used only for the direct administration of FoodShare Wisconsin. Case Name Agency Representative Name

Complete and sign the repayment agreement below and return this agreement no later than (Agency Address)

/

/

to:

Repayment Terms: You may repay the overissuance by one of the following: 1. 2. Initial - You may make an initial cash payment to repay all or part of the amount due. Monthly Payment - You may repay in monthly payments whether your case is open or closed. The minimum monthly payment . If your financial situation changes, you may request a re-negotiation of the repayment must be at least $ agreement. If you fail to make the monthly payments and your case is open the State will automatically collect any overissuance by reducing your FoodShare benefits each month. Benefits Reduction - If your case is open, you may repay the overissuance by reducing your monthly FoodShare benefits. The . minimum monthly payment must be at least $ Voluntary Payment ­ You can make voluntary payments, in addition to the minimum monthly payment, using your FoodShare benefits.

3. 4.

Monthly payments must be at least $10 if the overpayment is due to client or agency error and at least $20 if the overpayment was due to an Intentional Program Violation. If payments are missed and the debt becomes delinquent, this repayment agreement shall be null and void and the balance remaining on the overpayment shall be immediately due and owing and the agency will have the right to take collection actions to recover the entire overpayment. If this debt becomes delinquent the liable individual(s) may be subject
to additional processing fees.

Supplements: If you owe an overissuance amount and become eligible for a supplemental FoodShare allotment, we will credit the supplemental FoodShare allotment to the overissuance amount you owe. REPAYMENT AGREEMENT Cash repayments may be made electronically online at http://dwd.wisconsin.gov/epayment/ if you have a checking account. Please have your PIN available as you will need it to enter it into the electronic payment system. I AGREE TO REPAY (check one): 1. Initial Payment- In one cash payment in the amount of $ .

2. Monthly Payments - In monthly payments of $ . I understand that if I am currently receiving or if I receive FoodShare benefits in the future, any outstanding amount may be collected by reducing my FoodShare benefits. 3. Benefit Reduction - By reducing my current monthly FoodShare benefits by $ FoodShare benefits are terminated, any outstanding amount owed must be collected. 4. Voluntary Payments ­ Of $ above. Participant's Signature . I understand that if my

FoodShare benefits, in addition to the minimum monthly payment

Date Signed

7CFR 273.18

RETAIN COMPLETED FORM IN CASE RECORD

RESET FORM