Form F-16019B "Foodshare Wisconsin Application" - Wisconsin

What Is Form F-16019B?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-16019B by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-16019B "Foodshare Wisconsin Application" - Wisconsin

268 times
Rate (4.3 / 5) 19 votes
APP
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-16019B (07/2018)
FOODSHARE WISCONSIN APPLICATION
This application is for FoodShare only. This is not an application for Medicaid, BadgerCare Plus, Wisconsin Shares, or
Wisconsin Works (W-2). You can apply for Medicaid, BadgerCare Plus, and Wisconsin Shares online at
access.wi.gov
at
the same time you are applying for FoodShare. To apply for W-2, you must contact your agency. These programs can
provide you help with the cost of health care or child care or finding a job as part of W-2.
How to Use This Form
1. Do not write in the shaded sections.
2. Print clearly. Use blue or black ink.
3. Fill out the application completely. If you need more room to provide your answer, use a blank sheet of paper. Return
your application to your agency. To get the address of your agency, go to
www.dhs.wisconsin.gov/forwardhealth/
resources.htm
or call Member Services at 800-362-3002.
4. If you need help filling out this application, contact your agency.
5. If you want someone else to complete the application process for you, complete the Authorization of Representative
form (F-10126). You can get this form at
www.dhs.wisconsin.gov/forwardhealth/resources.htm
or from your agency.
SECTION 1 – CONTACT INFORMATION
Please tell us how we can contact you. Include the area code for all phone numbers.
Phone Number
Type of Phone
Home
Cell
Work
Other Phone Number
Who does this number belong to?
What is this person’s name?
Self
Friend
Neighbor
Relative
Email Address
What is the best way and time to contact you during the weekdays?
SECTION 2 – APPLICANT INFORMATION
If you are completing this application for someone else, answer the rest of the questions as if you were that person.
Name – Applicant (Last, First MI)
Date of Birth (mm/dd/yy)
Social Security Number
Street Address
City
State
Zip Code
Mailing Address – if different from your residence (include street or PO box
City
State
Zip Code
Sex
Marital Status
Male
Female
Married
Single
Divorced
U.S. Citizen (only for those applying)
Ethnicity (optional)
Yes
No
Hispanic
Other
Race (optional)
American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Other Pacific Islander
White
APP
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-16019B (07/2018)
FOODSHARE WISCONSIN APPLICATION
This application is for FoodShare only. This is not an application for Medicaid, BadgerCare Plus, Wisconsin Shares, or
Wisconsin Works (W-2). You can apply for Medicaid, BadgerCare Plus, and Wisconsin Shares online at
access.wi.gov
at
the same time you are applying for FoodShare. To apply for W-2, you must contact your agency. These programs can
provide you help with the cost of health care or child care or finding a job as part of W-2.
How to Use This Form
1. Do not write in the shaded sections.
2. Print clearly. Use blue or black ink.
3. Fill out the application completely. If you need more room to provide your answer, use a blank sheet of paper. Return
your application to your agency. To get the address of your agency, go to
www.dhs.wisconsin.gov/forwardhealth/
resources.htm
or call Member Services at 800-362-3002.
4. If you need help filling out this application, contact your agency.
5. If you want someone else to complete the application process for you, complete the Authorization of Representative
form (F-10126). You can get this form at
www.dhs.wisconsin.gov/forwardhealth/resources.htm
or from your agency.
SECTION 1 – CONTACT INFORMATION
Please tell us how we can contact you. Include the area code for all phone numbers.
Phone Number
Type of Phone
Home
Cell
Work
Other Phone Number
Who does this number belong to?
What is this person’s name?
Self
Friend
Neighbor
Relative
Email Address
What is the best way and time to contact you during the weekdays?
SECTION 2 – APPLICANT INFORMATION
If you are completing this application for someone else, answer the rest of the questions as if you were that person.
Name – Applicant (Last, First MI)
Date of Birth (mm/dd/yy)
Social Security Number
Street Address
City
State
Zip Code
Mailing Address – if different from your residence (include street or PO box
City
State
Zip Code
Sex
Marital Status
Male
Female
Married
Single
Divorced
U.S. Citizen (only for those applying)
Ethnicity (optional)
Yes
No
Hispanic
Other
Race (optional)
American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Other Pacific Islander
White
APP
FOODSHARE WISCONSIN APPLICATION
F-16019B
Page 2 of 8
In which language do you want FoodShare notices printed?
Primary Language Spoken in Your Home
SECTION 3 – HOUSEHOLD INFORMATION
If more room is needed, use a blank sheet of paper to answer these questions.
Name – Spouse or Other Adult (Last, First MI)
Is this person applying for FoodShare?
Yes
No
Date of Birth (mm/dd/yy)
Social Security Number (if applying)
Sex
Marital Status
Male
Female
Married
Single
Divorced
U.S. Citizen (only for those applying)
Ethnicity (optional)
Yes
No
Hispanic
Other
Race (optional)
American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Other Pacific Islander
White
Relationship to Applicant
Do you share food with this person?
Do you provide care for this person?
Yes
No
Yes
No
Name – Child 1 (Last, First MI)
Is this person applying for FoodShare?
Yes
No
Date of Birth (mm/dd/yy)
Social Security Number (if applying)
Sex
Male
Female
Marital Status
Race or Ethnicity (optional)
U.S. Citizen (only for those applying)
Married
Single
Divorced
Yes
No
Relationship to Applicant
Do you share food with this person?
Do you provide care for this person?
Yes
No
Yes
No
Name – Child 2 (Last, First MI)
Is this person applying for FoodShare?
Yes
No
Date of Birth (mm/dd/yy)
Social Security Number (if applying)
Sex
Male
Female
Marital Status
Race or Ethnicity (optional)
U.S. Citizen (only for those applying)
Married
Single
Divorced
Yes
No
Relationship to Applicant
Do you share food with this person?
Do you provide care for this person?
Yes
No
Yes
No
Name – Child 3 (Last, First MI)
Is this person applying for FoodShare?
Yes
No
Date of Birth (mm/dd/yy)
Social Security Number (if applying)
Sex
Male
Female
Marital Status
Race or Ethnicity (optional)
U.S. Citizen (only for those applying)
Married
Single
Divorced
Yes
No
APP
FOODSHARE WISCONSIN APPLICATION
F-16019B
Page 3 of 8
Relationship to Applicant
Do you share food with this person?
Do you provide care for this person?
Yes
No
Yes
No
SECTION 4 – STUDENT INFORMATION
If more room is needed, use a separate sheet of paper.
Is there anyone 18–49 years of age attending school?
Name – Student (Last, First MI)
Yes
No
If no, go to Section 5.
Name of School
The student is enrolled:
Part time
Full time
Is the student employed at least 20 hours per week?
Is the student caring for a child under 6 years of age?
Yes
No
Yes
No
Is the student caring for a child 6–12 years of age where adequate day care is not available?
Yes
No
Is the student a single parent caring for a child less than 12 years of age and attending school full time?
Yes
No
Is the student participating in a federally or state-funded work study program?
Yes
No
Is the student unable to work due to a temporary or permanent disability?
Yes
No
Is the student attending school due to placement through Workforce Innovation and Opportunity Act (WIOA), W-2, or
FoodShare Employment and Training (FSET)?
Yes
No
SECTION 5 – ADDITIONAL HOUSEHOLD INFORMATION
Has anyone been found totally disabled by the Social Security Administration, Veterans Administration, or Railroad
Retirement Board?
Yes
No
Name (Last, First MI)
Date of Disability Determination (mm/dd/yy)
Has anyone been convicted of a drug felony?
Name (Last, First MI)
Date of Conviction (mm/dd/yy)
Yes
No
Is anyone a fleeing felon or in violation of probation/parole?
Name (Last, First MI)
Yes
No
SECTION 6 – ABSENT PARENT INFORMATION
Do any children have a biological or adoptive mother or father who is not living at home?
Yes
No
Name of Absent Parent (Last, First MI)
Social Security Number
Date of Birth (mm/dd/yy)
Name(s) of Child(ren)
Relationship to Child(ren)
Mother
Father
Date Parent Left Household (mm/dd/yy)
Date Last Contact With Parent (mm/dd/yy)
APP
FOODSHARE WISCONSIN APPLICATION
F-16019B
Page 4 of 8
Court Order of Divorce / Paternity
Case Number
County
State
Reason for Parent’s Absence
Name of Absent Parent (Last, First MI)
Social Security Number
Date of Birth (mm/dd/yy)
Name(s) of Child(ren)
Relationship to Child(ren)
Mother
Father
Date Parent Left Household (mm/dd/yy)
Date Last Contact With Parent (mm/dd/yy)
Court Order of Divorce / Paternity
Case Number
County
State
Reason for Parent’s Absence
SECTION 7 – ASSETS
Asset information is only needed if you are applying for emergency benefits or a household of elderly, blind, or disabled
individuals. List all assets owned by the applicant(s). Include assets owned jointly with anyone else. Do not include the
value of personal household belongings. Available assets mean any asset that can be cashed at any time. Assets include
items such as cash, checking or savings accounts, certificates of deposit, trust funds, stocks, bonds (not set aside for
education, or funeral expenses), interest in annuities, U.S. savings bonds, property agreements, contracts for deeds,
timeshares, rental property, life estates, or personal property being held for investment purposes.
Current
Description (such as name of bank or
Type of Asset
Name of the Owner(s)
Value
financial institution, account number)
$
Cash
$
Checking Account
$
Savings Account
$
Other Type of Asset
$
Other Type of Asset
$
Other Type of Asset
SECTION 8 – EMPLOYMENT/JOB INCOME AND WAGES
Enrollment in FoodShare is based on total household income. Do not list self-employment in this section. Self-
employment will be entered in Section 10. If more room is needed, use a separate sheet of paper.
Is anyone listed below a migrant
Is any household member working? If yes, answer questions below for each
worker?
household member who is working.
Yes
No
Yes
No
Name of Person Working
Date Employment Began (mm/dd/yy)
APP
FOODSHARE WISCONSIN APPLICATION
F-16019B
Page 5 of 8
Employer Name and Address
How Often Paid
Number of Hours in Pay Period
Weekly
Biweekly
Once per month
How Much Paid Per Hour
Gross Earnings (before taxes) Per Pay Period
$
$
Name of Person Working
Date Employment Began (mm/dd/yy)
Employer Name and Address
How Often Paid
Number of Hours in Pay Period
Weekly
Biweekly
Once per month
How Much Paid Per Hour
Gross Earnings (before taxes) Per Pay Period
$
$
SECTION 9 – LOSS OF EMPLOYMENT
Has anyone recently ended employment? If yes, complete the rest of Section 9.
Yes
No
Name (Last, First MI)
Date Job Ended (mm/dd/yy)
Employer Name and Address
Reason Employment Ended
Has this person applied for unemployment insurance?
Quit
Fired
Laid off
Other
Yes
No
SECTION 10 – SELF-EMPLOYMENT INCOME
List the amounts you reported to the IRS on your tax form. If you did not file taxes last year, leave the net annual income
and depreciation boxes empty. Your agency will contact you for more information.
Is anyone in your home self-employed? If yes, complete the following. If no, go to Section 11 – Other Income.
Yes
No
Type of Self-Employment
Name – Business
When did this self-employment begin?
What is the most recent year federal taxes were filed for this business?
Has there been a significant change to the average annual income and expenses for this business since the most recent
taxes were filed?
Yes
No
Name – Self-Employed Person
How many hours are worked each month?
Net Annual Income (after business expenses)
Depreciation Amount Claimed
$
$