DISASTER FOODSHARE APPLICATION
F-16060
Page 1 of 4
STATE OF WISCONSINDEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-16060 (09/2017)
disaster foodshare application
PURPOSE: This application is to apply for emergency FoodShare benefits if your household lives in an area the federal government has declared a federal disaster or if any member of your household works in a federal disaster area. In Wisconsin, this program is called Disaster FoodShare (referred to federally as the Disaster Supplemental Nutrition Assistance Program [DSNAP]).Note: If you are already getting FoodShare benefits, do not fill out this form. Instead, fill out the FoodShare Affidavit of Lost Income or Costs from a Disaster, F16106. To get this form, ask your agency.
INSTRUCTIONS: Complete this application and return it to your agency. To find your agency, go to or call Member Services at 18003623002. Use an additional sheet of paper if you need more room to write your responses. Do not write in shaded areas.
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. Translation services are free of charge.
You will be required to show proof of your identity. You may also be asked to show proof of one of the following, if possible:
- Your household was living in the designated disaster area at the time of the disaster.
- Someone in your household was working in the designated disaster area at the time of the disaster.
Social Security numbers (SSNs) and personally identifiable information will be used only for the direct administration of the FoodShare program. Providing SSNs allows for the information you provided, such as identity and income, to be checked with government agencies, employers, banks, and other parties.
Authorized Representative
You have the right to have another person apply for Disaster FoodShare benefits for you. This person will act as an authorized representative. If you want to have an authorized representative, complete the Authorization of Representative form (F10126). To get this form, go to or ask your agency. If an authorized representative provides wrong information that is used to determine your Disaster FoodShare benefits, you will be responsible for any mistakes.
FOR OFFICE USE ONLY – DISASTER PERIOD
Begin Date / End Date / Application Date / Number
SECTION I – APPLICANT INFORMATION
Name – Applicant (Last, First, Middle Initial) / Verified / Authorized Representative
Click here to enter text. / Click here to enter text.
Permanent Home Address – Street Address / Verified / Temporary Address – Street Address
Click here to enter text. / Click here to enter text.
City / City
Click here to enter text. / Click here to enter text.
State / Zip Code / Phone Number / State / Zip Code / Phone Number
text / text / text / text / text / text
SECTION II – HOUSEHOLD SITUATION / Yes / No
- Was your household living in the disaster area at the time of the disaster or was at least one person in your household working in the disaster area at the time of the disaster? If yes, answer the following questions.
- Did the disaster cause damage to or destroy your home or self-employment property during the disaster period?
- Did the disaster cause your household to have additional costs during the disaster period?
- During the disaster cleanup, will your household need to buy food?
- Did the disaster delay, reduce, or stop your household’s income?
- Does your household have any cash or money in checking or savings accounts that you cannot get because the bank is closed due to the disaster?
- Do you currently get FoodShare or Supplemental Nutrition Assistance Program (SNAP) benefits?
- If your food was destroyed or lost during the disaster period, what was the dollar amount of food that was destroyed or lost?
- Is anyone in your household a county/state/contracted employee working in an income maintenance (IM)/child care (CC)/Wisconsin Works (W2) agency?
SECTION III – HOUSEHOLD MEMBERS
Provide the information below for yourself and any members of your household who were living with you at the time of the disaster and who regularly eat with you. List each household member’s SSN (if available), date of birth, source/type of income, and net income. Net income is what you make after taxes. List any other income your household members have received or expect to receive during the 30-day disaster period, fromenter a datethroughenter a date.
Note: If you are temporarily staying with another household because of the disaster, do not list members of that household.
Name (Last, First, MI) / Social Security Number / Date of Birth / Source/Type of Income / Income
Click here to enter text. / enter text. / date. / enter text. / $text.
Click here to enter text. / enter text. / date. / enter text. / $text.
Click here to enter text. / enter text. / date. / enter text. / $text.
Click here to enter text. / enter text. / date. / enter text. / $text.
Click here to enter text. / enter text. / date. / enter text. / $text.
Click here to enter text. / enter text. / date. / enter text. / $text.
SECTION IV – MONEY YOU HAD ACCESS TO
List all money your household had access to during the disaster. Include cash and money you had in checking and savings accounts. / Total Amount Available
$to enter text.
SECTION V – DISASTER-RELATED COSTS
For each item below, list the amount your household has paid or expects to pay due to the disaster.
Note: Do not include any costs that did not occur during the disaster period. Do not include any costs that are not due to the disaster or that were paid or will be paid by someone outside of your household.
Type of Cost / Amount / Type of Cost / Amount
Food destroyed or lost / $ enter a. / Property protection / $ enter a.
Dependent care / $ enter a. / Temporary shelter / $ enter a.
Funeral/medical / $ enter a. / Repair or replace items for home or self-employment property / $ enter a.
Moving and storage / $ enter a. / Other disaster-related costs / $ enter a.
SECTION VI – ELIGIBILITY CALCULATION
FOR OFFICE USE ONLY
1.Anticipated income
2.Accessible cash
3.Total income/cash (Line 1 plus Line 2)
4.Total out-of-pocket disaster expenses
5.Reimbursed disaster-related expenses / $
$
$
$
$ / 6.Net disaster expenses (Line 4 minus Line 5)
7.Net income (Line 3 minus Line 6)
8.Maximum income limit
9.Eligible (“Yes” if Line 7 [net income] is less than or equal to Line 8 [maximum income limit]; “No” if Line 7 is greater than Line 8) / $
$
$
$
SECTION VII – FOODSHARE FRAUD / INTENTIONAL PROGRAM VIOLATION
If any information you give is found to be incorrect, you may be denied benefits and/or be subject to criminal prosecution for knowingly providing false information.
You must repay any benefits you received because you gave false information.
If a FoodShare claim is filed against your household, the information on your application, including all Social Security numbers, may be referred to federal and state agencies, as well as private claims and collection agencies, for claims collection action.
Fraud or intentional program violations by a person in your household may result in his or her disqualification from FoodShare. This means the person will not be able to get FoodShare benefits:
- For one year after the first violation.
- For two years after the second violation.
- Permanently for the third violation.
Depending upon the value of misused benefits, the person who committed the fraud or program violation can also be fined up to $250,000 and/or imprisoned up to 20 years. A court can also bar the person from the program for an additional 18 months. A person will also be permanently barred if convicted of trafficking benefits of $500 or more.
You will not be able to get benefitsfor 10 years if you are found to have made a false statement about your identity and where you live in order to receive multiple benefits at the same time.
SECTION VIII – NONDISCRIMINATION
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA 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 (e.g. 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.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1)mail:U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)fax: (202) 690-7442; or
(3)email: .
This institution is an equal opportunity provider.
SECTION IX – CERTIFICATION AND SIGNATURE
I understand the questions and statements on this application form. I understand the penalties for giving false information or breaking the rules. I certify, under penalty of perjury and false swearing, that all my answers are correct and complete to the best of my knowledge. I understand and agree to provide proof of the answers I provided. I understand that my agency may contact other people or organizations to obtain the necessary proof of my eligibility and level of benefits.
I understand that if I disagree with any action taken on my case, I have the right to request a fair hearing orally or in writing. When a decision is made about the benefits you are applying for, you will get a letter about this decision that includes information about how to request a fair hearing.
Two witnesses are required if signed with an X.
SIGNATURE – Applicant/Authorized Representative / Date SignedSIGNATURE – Witness (required if signed with an X) / Date Signed
SIGNATURE – Witness (required if signed with an X) / Date Signed