Wisconsin FoodShare (SNAP) Application

The date this application is being submitted

Print the full name of the person signing this application

Digital signature of the applicant or authorized representative. By typing your name here, you are providing your electronic signature.

Date the application was signed

Full name of the authorized representative if different from applicant

How is the authorized representative related to or connected to the household?

Describe the documentation provided establishing authority to act for the household (signed statement, power of attorney, court documentation, etc.)

Primary name for this household application

Street address where the household resides

County where the household resides

Primary contact phone number for the household

Email address for household communications

Total number of people who live together and purchase and prepare meals together

Includes anyone receiving disability benefits or unable to work due to disability

Complete mailing address if different from home address

Total monthly gross income for all household members from all sources

Total liquid resources available to the household

Enter the average number of hours you work per week

Include wages, salaries, tips, and commissions before any deductions

Enter your self-employment income after deducting allowable business expenses

Please list each source of income and the monthly amount (e.g., TANF $200, Rental income $500, etc.)

This is used for expedited service screening and benefit calculation

Include cash, checking accounts, savings accounts, and any other liquid resources available to your household

Enter the current value of any savings certificates, stocks, bonds, or other investments

Enter the fair market value minus any loans owed on vehicles that exceed the state exclusion limits

Enter the value of property, tools, or equipment essential to your employment or business

Include any other countable resources such as land that is not your home, additional real estate, etc.

Your home and surrounding property are excluded from resource limits

Include tax refunds, insurance settlements, retroactive Social Security or SSI payments, etc.

Provide details about each lump-sum payment including source, amount, and date received

Enter the amount you pay each month for rent or mortgage payments. If you own your home free and clear, enter $0.

If you pay property taxes, enter the monthly amount. If paid annually, divide by 12.

Enter monthly homeowner's or renter's insurance premium. If paid annually, divide by 12.

Enter monthly condo fees or cooperative housing fees, if applicable.

Enter your average monthly electricity bill. Only complete if claiming actual utility costs.

Enter your average monthly gas or heating bill. Only complete if claiming actual utility costs.

Enter your average monthly water and sewer bill. Only complete if claiming actual utility costs.

Enter your average monthly telephone bill (landline and/or cell phone). Only complete if claiming actual utility costs.

Enter any other utility costs such as trash collection, internet, or cable. Only complete if claiming actual utility costs.

Medical expenses include prescription drugs, medical supplies, health insurance premiums, and transportation to medical appointments. Only expenses for elderly (60+) or disabled members can be deducted.

Enter only the portion of medical expenses that exceeds $35 per month. Include prescription drugs, medical supplies, health insurance premiums, and transportation to medical appointments for elderly or disabled members.

Dependent care costs include expenses for child care or care for disabled adults when necessary for a household member to work, seek employment, or attend training or education.

Enter the actual monthly cost for dependent care when necessary for work, job training, or education. Include care for children or disabled adults.

Name of the household member(s) who receive dependent care services.