STATE OF WISCONSIN CHG DEPARTMENT OF HEALTH OF WISCONSIN CHG . DEPARTMENT OF HEALTH SERVICES . Division of Medicaid Services F-16066BU (10/2017) FOODSHARE WISCONSIN ၀င္ေငြ ေ

  • View
    225

  • Download
    11

Embed Size (px)

Transcript

  • CHG STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-16066BU (10/2017)

    FOODSHARE WISCONSIN ( )

    FOODSHARE WISCONSIN INCOME CHANGE REPORT (REDUCED REPORTING HOUSEHOLDS)

    80 * 10 -

    access.wisconsin.gov

    Milwaukee County - MDPU PO Box 05676 Milwaukee WI 53205 Fax: 1-888-409-1979

    Milwaukee County CDPU PO Box 5234 Janesville, WI 53547-5234 Fax: 1-855-293-1822

    www.dhs.wisconsin.gov/forwardhealth/resources.htm 1-800-362-3002 711 (TTY)

    - 1 FoodShare * $2,213 10 FoodShare

    *

    1 2017 30 2018 *

    1 $1,307 6 $3,571 2 $1,760 7 $4,024 3 $2,213 8 $4,477 4 $2,665 9 $4,930 5 $3,118 10 $5,383

    * 2017-2018 $453

    https://access.wisconsin.gov/https://www.dhs.wisconsin.gov/forwardhealth/resources.htm

  • FOODSHARE WISCONSIN INCOME CHANGE REPORT F-16066BU Page 2 of 4

    CHG

    FoodShare Wisconsin

    $

    Federal Law 7: CFR273.12(b) ( W-2 )

    $

    $

    + $

    = $

  • FOODSHARE WISCONSIN INCOME CHANGE REPORT F-16066BU Page 3 of 4

    CHG FoodShare

    FoodShare FoodShare

    FOODSHARE WISCONSIN Foodshare Wisconsin 12 24

    FoodShare FoodShare FoodShare FoodShare

    $250,000 20 18 FoodShare Wisconsin FoodShare $500 Food Share 10

    / FoodShare ( ) FoodShare ( ) FoodShare Wisconsin

    USDA U.S. Department of Agriculture (USDA) USDA USDA USDA

  • FOODSHARE WISCONSIN INCOME CHANGE REPORT F-16066BU Page 4 of 4

    CHG ( Braille American Sign Language ) ( ) USDA (800) 877-8339 Federal Relay Service

    http://www.ascr.usda.gov/how-file-program-discrimation-complaint USDA USDA Program Discrimination Complaint Form (AD-3027) USDA (866) 632-9992 USDA -

    (1) - U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

    (2) - (202) 690-7442

    (3) - program.intake@usda.gov

    /

    RETAIN COMPLETED FORM IN CASE FILE

    http://www.ascr.usda.gov/how-file-program-discrimation-complainthttp://www.ascr.usda.gov/how-file-program-discrimation-complaintmailto:program.intake@usda.gov

    FOODSHARE WISCONSIN ( )FOODSHARE WISCONSIN INCOME CHANGE REPORT (REDUCED REPORTING HOUSEHOLDS)

    Your Name: Case Number: Name of Employed Person: Employer: Rate of Pay Per Hour: Hours Per Week: How Often Paid: First Pay Date: Name Person Receiving Unearned Income: Date Income Changed: Source of Income: New Monthly Amount: Month of Change: Number of People in Household: Total Monthly Gross Unearned Income: Total Monthly Gross Job Income and Wages: Total Household Gross Monthly Income: Do you expect that the changes reported on this form will remain the same next month: If no, explain below: Daytime Telephone Number (include area code): Reset Form: