Form F 16006 – Fill Out and Use This PDF

•Address and shelter cost,

•Income or employment status, or

•Household (someone moves in or out of your home, if anyone gets married, becomes pregnant, or gives birth to a child).

If such a change happens, you can:

•Report it online at ACCESS.wi.gov or

•Fill out this report and mail or fax it 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
Fax: 1-888-409-1979	Fax: 1-855-293-1822

•Or, you can call or take it to your local agency. You can get the address and telephone for your local agency at dhs.wi.gov/em/customerhelp or by calling 1-800-362-3002 or 711 (TTY).

If this report does not have enough room for you to explain a change, write the information on a sheet of paper and attach it to this report.

Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants FoodShare beneits but does not provide an SSN or apply for one will not be able to get beneits. SSNs and personally identiiable information will be used only for the direct administration of FoodShare Wisconsin.

If you intentionally fail to report any changes or give false information you may be ined, have to pay back any FoodShare beneits you wrongfully get, be prosecuted, or all three.

CHANGE IN JOB INCOME AND WAGES

NEW JOB - 1

You must report and give proof of any new source of earned income. Examples of proof are check stubs, a letter from the employer or an Employer Veriication of Earnings form (F-10146).

Name of person with new job or income	Rate of Pay per hour	Hours per week
	$
Employer	How often paid	First pay date

Federal Law 7CFR273.12(b)

Name of person with new job or income	Rate of Pay per hour	Hours per week
	$
Employer	How often paid	First pay date

CHANGE IN OTHER INCOME

You must report any

•New source of other income,

•Change of more than $100 per month in child support income, or

•Change of more than $50 per month in other types of unearned income such as Worker’s Compensation, Unemployment Insurance, Social Security or Veterans beneits.

Name of person receiving unearned income		Source of income
Income change  Yes  No	Date income changed	Monthly amount
		$
Name of person receiving unearned income		Source of income
Income change  Yes  No	Date income changed	Monthly amount
		$

CHANGE IN ADDRESS AND RESULTING CHANGES IN SHELTER COSTS

If you move, you must report your new address, any increase or decrease in your rent or mortgage payment, or utility bills (gas, electric, water, etc.).

CHANGE IN RENT

Are you in subsidized housing? Yes  No	New monthly rent amount	$
Landlord name	Landlord telephone number (include area code)
Landlord address – Street	City		State	ZIP Code
List utilities you must pay

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If not included in mortgage, list the monthly amount of

Property tax $

Insurance $

CHANGE IN HOUSEHOLD

You must report if anyone:

•Moves in or out of your household

•Gets married

•Becomes pregnant

•Gives birth to a baby (include information about the person who gave birth and the newborn)

Name(s)		Social Security Number(s) (SSN)
Date of Birth	Relationship to You	Date of Change
Describe change

CHANGE IN CHILD SUPPORT PAYMENTS

You must report any changes in the legal obligation of any household member to pay child support.

Name of person court-ordered to pay child support	Court Order Number
Amount of monthly child support order	Date of court order or date the order was changed
$

OTHER CHANGES?

Report any other changes which might affect your eligibility. Some examples of other changes include someone becom- ing disabled or recovering from a disability, someone dropping out of school, out of pocket medical expenses, etc. Include the date of the change.

Do you expect that the changes reported on this form will remain the same next month?  Yes  No If no, explain.

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Any member of your household who intentionally breaks any of the following rules can be barred from FoodShare Wisconsin for

12 months after the irst violation, 24 months after the second violation or for a irst violation involving a controlled substance, and permanently for the third violation:

•Giving false information or hiding information to get or continue FoodShare beneits,

•Trading, selling or altering FoodShare beneits,

•Using FoodShare beneits to buy non-food items, like alcohol or tobacco, or

•Using another person’s FoodShare beneits, identiication cards or other documentation.

Depending upon the value of misused beneits, the individual can also be ined up to $250,000, imprisoned up to 20 years, or both. A court can also bar an individual from the program for an additional 18 months. You will also be permanently disqualiied if you are convicted of traficking FoodShare beneits of $500 or more. You will be ineligible to participate for 10 years if you are found to have made a fraudulent statement or representation with respect to identity and residence in order to receive multiple beneits at the same time. Fleeing felons and probation/parole violators are ineligible for the program. The individual may also be subject to further prosecution under other applicable federal laws.

Expenses: I understand that expenses I report such as shelter, utility, child care, child support, or medical costs may affect the level of FoodShare beneits my household receives. I understand that failure to report or verify an expense means that I do not want to receive a deduction for this expense.

Income Reduction: I understand that I am not required to report a reduction or loss of income; however, I may be entitled to a higher FoodShare beneit if I do. I understand that as long as I do not report a reduction in my household’s monthly income or the loss of any household income, that I will not receive any resulting increase in my FoodShare beneit.

I understand there are penalties for hiding information or giving false information. I also understand I will have to pay back any beneits I receive because I do not fully report changes in my circumstances. I agree to provide proof of any changes, if asked to do so. My answers on this form are correct and complete to the best of my knowledge.

Your SSN permits a computer check of your information with government agencies such as the Internal Revenue Service (IRS), Social Security Administration (SSA) and the Department of Workforce Development, as well as the School Lunch Program. Social Security numbers are also used to check the identity of household members and to verify income from such sources as employers, banks and other parties.

NON-DISCRIMINATION

The Department of Health Services (DHS) is an equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format, or need it translated to another language, please contact (608) 266-3356 (voice) or (888) 701-1251 (TTY).

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the base of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected by genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities).

If you wish to ile a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at ascr.usda.gov/complaint_iling_cust.html, or at any USDA ofice, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Ofice of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800)

877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers; found online at fns.usda.gov/snap/contact_info/hotlines.htm. USDA is an equal opportunity provider

and employer.

SIGNATURE – Participant/Authorized Representative	Date Signed	Daytime Telephone Number
		(	)

RETAIN COMPLETED FORM IN CASE FILE

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