Free FoodShare Wisconsin Worksheet, F-16033 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16033 (10/08)

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FOODSHARE WISCONSIN WORKSHEET

Case Name

Worker Name

Case Number

MONTH AND YEAR Elderly or disabled member? LINE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ENTER ENTER ENTER ENTER ADD ENTER ADD ENTER ENTER ENTER ENTER ENTER ENTER ADD SUBTRACT ENTER ENTER SUBTRACT ENTER SUBTRACT

YES

NO

YES

NO

YES

NO

NUMBER IN GROUP
Total Assets Asset Limit (FSH 8.3.3) Earned Income Room and Board Earned Income Total Earned Income ( Lines 3 + 4) Total Unearned Income Including W-2 Payment Total Gross Income (Lines 5 + 6) Gross Income Limit (FSH 8.1.4) Excess Medical Expenses (Elderly , Disabled Only) Earned Income Deduction (20% of line 5) Standard Deduction (FSH 8.1.5) Child Support Payment Deduction Dependent Care Deduction (FSH 4.6.6 or 8.1.5) Subtotal Deduction (Add Lines 9 Through 13) Subtotal Net Income (Line 7 Minus Line 14) Total Shelter Expense Line I on Back of Worksheet 50% Of Line 15 Shelter Deduction (Line 16 minus Line 17) Shelter Maximum (No Cap Elderly/Blind/Disabled) - (FSH 4.6.7 or 8.1.5) Total Adjusted Net Income (Line 15 Minus Line 18 for Elderly/Blind/Disabled. All other cases use Line 18 or Line 19, whichever is less. Net Income Limit (FSH 8.1.1) Monthly Allotment (Compare Adjusted Net Income to Group Size (FSH 8.1.8) Initial Allotment (prorate if applicable²) Monthly Recoupment Amount Allotment Due (Line 23 minus Line 24) Actual Allotment Issued Line 26 Minus Line 25 Negative ­ Overpay Positive - Underpay
4 4

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

21 22 23 24 25 26

ENTER ENTER ENTER ENTER ENTER ENTER

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

27

SUBTRACT

Line 26 minus 25

FOODSHARE WISCONSIN WORKSHEET F-16033 (10/08)

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1. Use full dollar and cents amounts through line 20.

2. Prorate monthly allotment by dividing by the number of days remaining in the month including the application date by the total number of days in the month. Multiply the result by the monthly allotment (line 23) = initial allotment; round down 1 cent through 99 cents. 3. Use lesser of 18 or 19 unless EBD. Use18 if EBD. 4. Line 27 is used for manual overpayment/underpayment calculations only.

A B C D E F G H I

ENTER ENTER

Appropriate Utility Standard (FSH 4.6.7.2) Rent Mobile Home Lot Rent Mobile Home Loan Payments Home Mortgage Payments Property Taxes (If Not Included In Mortgage) Special Assessments Insurance on the Structure (If Not Included In Mortgage)

$ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $

ADD

"Total Shelter Expense" (Add lines A through H)

Enter the total shelter expense form line "I" on line 16 on page 1 of worksheet..

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