FoodShare Wisconsin Application

1 Registration Packet March 2019. F-16019B. Wisconsin DEPARTMENT OF HEALTH SERVICES. Division of Medicaid Services F-16019A (07/2018). APP. FoodShare Wisconsin REGISTRATION. If you have a disability and need to access this Application in an alternate format or need it translated to another language, please contact your agency. To get the phone number of your agency, go to or call Member Services at 800-362-3002. Translation services are free of charge. You may have another adult complete the Application for you. If your FoodShare benefits stopped within the last 30 days, you may complete this Application or contact your agency to find out if you can reopen your FoodShare benefits without completing this Application .

2 If you are found eligible for FoodShare , your FoodShare benefits will start on the date your Application is received by your agency. Your Application will be processed as soon as possible but no later than 30 days from the date your Application is received by your agency. Name Applicant (Last, First MI). Social Security Number (optional) Date of Birth (mm/dd/yy optional) Phone Number (optional). Street Address City State Zip Code SIGNATURE Applicant or Authorized Representative Date Signed (mm/dd/yy). Priority FoodShare Services If you need help right away, you may be able to get FoodShare benefits within seven days of providing your Application and/or registration form if any of the following are true: Your household has $100 or less available in cash or in the bank and expects to receive less than $150 of income this month.

3 Your household has rent, mortgage, or utility costs that are more than your total gross monthly income (available cash or in bank accounts) for this month. Your household includes a migrant or seasonal farm worker whose income has stopped. Answer the following questions to be considered for faster service. What is the total gross income expected by your household this month (before taxes or other $. deductions)? What are your household's total available assets (for example, cash or money in checking or savings $. accounts or a lump sum of money)? What is the amount your household pays in total for rent or mortgage this month? $. Did your household receive Wisconsin FoodShare benefits this month?

4 Yes No Are you currently residing in a shelter for victims of domestic violence? Yes No Did your household receive Supplemental Nutrition Assistance Program (SNAP, food stamps, Yes No electronic benefits transfer) benefits in another state this month? Is anyone in your household a migrant or seasonal farm worker whose income has recently stopped Yes No and who does not expect to receive more than $25 in income in the next 10 days? If your household has to pay utilities, answer the following questions. If you pay rent, is heat included in your rent? Yes No Check the box(es) for the utilities your household is required to pay and check Yes or No to tell us whether the utility is used to heat your home.

5 Used for heat? Used for heat? Gas (natural) Yes No Fuel oil/kerosene Yes No Electric Yes No Coal Yes No Liquid propane gas Yes No Wood Yes No Check the box(es) for the utilities your household is required to pay. Phone Water Sewer Trash removal Installation Other: RESET FORM. FoodShare Wisconsin REGISTRATION. F-16019A. Page 2 of 8. You have the right to submit your Application at any time. To set your filing date (which is the date your benefits can start) you must provide at least your name, address, and signature. You can then complete a full Application online at , by mail, by fax, by phone, or in person. You will need to have an interview with your agency in person or over the phone in order to finish the rest of your Application .

6 You may have to provide proof of some of your answers. See Proof Needed for a list of proof you may need to give us. Mail or fax applications and/or proof/verifications to: If you live in Milwaukee County: If you do not live in Milwaukee County: MDPU CDPU. PO Box 05676 PO Box 5234. Milwaukee, WI 53205 Janesville, WI 53547-5234. Or fax: 888-409-1979 Or fax: 855-293-1822. You can also scan and upload any proof online at If you want to apply for BadgerCare Plus or Medicaid, you can apply for these health care programs online at at the same time you are applying for FoodShare benefits. Or you can complete a paper Application for health care. applications can be found online at Or you can get them by contacting your agency.

7 FoodShare Wisconsin IMPORTANT INFORMATION. This Application is for FoodShare benefits only. It is not an Application for BadgerCare Plus, Family Planning Only Services, Medicaid, Wisconsin Shares Child Care Subsidy, or Wisconsin Works (W-2). You can apply for BadgerCare Plus, Family Planning Only Services, Medicaid, and Wisconsin Shares online at at the same time you are applying for FoodShare . You must contact your agency to apply for 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.

8 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 . You have the right to be notified of your enrollment status within 30 days of applying. You have the right to receive benefits within seven days if you qualify for immediate help. You have the right to be treated with respect and not be discriminated against because of age, sex, race, color, disability, religious creed, national origin, or political beliefs. You are responsible for: Answering all questions on the Application completely and honestly and signing your name to certify, under penalty of perjury, that all your answers are true and correct.

9 Providing proof of all information needed to determine eligibility. Reporting required changes within the time frame provided to you in your notices. Not putting your money or possessions in someone else's name to be able to receive benefits. Not selling, trading, or giving away benefits. Using FoodShare benefits only to buy allowed items. People who break FoodShare rules may be disqualified from the program, fined, imprisoned or all three. FoodShare Wisconsin REGISTRATION. F-16019A. Page 3 of 8. USDA NONDISCRIMINATION STATEMENT. In accordance with Federal civil rights law and Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA.

10 Programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information ( Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.