A digital services project by FlexionWisconsin FoodShare (SNAP) Application
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1.Application Information and Signature
- Application Information and Signature
- Application Datedate
- I certify under penalty of perjury that all information provided in this application is true and complete to the best of my knowledgeboolean
- I understand that I must use FoodShare benefits only to purchase eligible food for my householdboolean
- I understand that providing false information is subject to prosecution under state and federal lawboolean
- I acknowledge that I have received and understand my rights and responsibilities under the FoodShare programboolean
- I authorize the State agency to verify the information I have provided through collateral contacts, computer matches, and other means permitted by lawboolean
- Applicant Full Name (Print)text
- Applicant Signaturetext
- Signature Datedate
- Is this application being signed by an authorized representative on behalf of the household?boolean
- Authorized Representative Nametext
- Relationship to Householdtext
- Authorization DocumentationlongText
2.Household Information
- Household Information
- Household Nametext
- Street Addresstext
- Citytext
- Statetext
- ZIP Codetext
- Countytext
- Phone Numberphone
- Email Addressemail
- Total Number of People in Householdnumber
- Is anyone in the household 60 years of age or older?boolean
- Is anyone in the household disabled?boolean
- Does the household have a current mailing address different from the home address?boolean
- Mailing Address (if different)longText
- Monthly Gross Income (before taxes and deductions)currency
- Cash on hand, checking and savings accountscurrency
3.Employment and Income
- Employment and Income
- Are you currently employed?boolean
- What is your job title or type of work?text
- Employer nametext
- How many hours per week do you work?number
- What is your gross monthly income from employment? (before taxes and deductions)currency
- Are you self-employed?boolean
- What is your net monthly income from self-employment? (after allowable business expenses)currency
- Do you receive unemployment compensation?boolean
- Monthly unemployment compensation amountcurrency
- Do you receive Social Security benefits?boolean
- Monthly Social Security benefits amountcurrency
- Do you receive SSI (Supplemental Security Income)?boolean
- Monthly SSI amountcurrency
- Do you receive veterans' benefits?boolean
- Monthly veterans' benefits amountcurrency
- Do you receive any other income? (TANF, General Assistance, pensions, rental income, interest, dividends, child support, etc.)boolean
- List all other sources of income and monthly amountslongText
- What is your total monthly gross income from all sources?currency
4.Resources and Assets
- Resources and Assets
- Total cash on hand (including money in checking and savings accounts)currency
- Savings certificates, stocks, bonds, or other investmentscurrency
- Value of vehicles owned (exclude one vehicle per adult household member)currency
- Property used for work or self-employmentcurrency
- Other resources not listed abovecurrency
- Do you own your home?boolean
- Have you received any lump-sum payments in the past 12 months?boolean
- Describe the lump-sum payment(s) and amount(s)longText
5.Housing and Shelter Costs
6.Medical and Dependent Care Expenses
7.Student and Work Requirements
9.Rights and Responsibilities
Groups
Application Information and Signature
| Field | Type | Required | Conditions | Status |
|---|---|---|---|---|
| Application Date The date this application is being submitted | Date | Yes | — | |
| I certify under penalty of perjury that all information provided in this application is true and complete to the best of my knowledge | Boolean | Yes | — | |
| I understand that I must use FoodShare benefits only to purchase eligible food for my household | Boolean | Yes | — | |
| I understand that providing false information is subject to prosecution under state and federal law | Boolean | Yes | — | |
| I acknowledge that I have received and understand my rights and responsibilities under the FoodShare program | Boolean | Yes | — | |
| I authorize the State agency to verify the information I have provided through collateral contacts, computer matches, and other means permitted by law | Boolean | Yes | — | |
| Applicant Full Name (Print) Print the full name of the person signing this application | Text | Yes | — | |
| Applicant Signature Digital signature of the applicant or authorized representative. By typing your name here, you are providing your electronic signature. | Text | Yes | — | |
| Signature Date Date the application was signed | Date | Yes | — | |
| Is this application being signed by an authorized representative on behalf of the household? | Boolean | Yes | — | |
| Authorized Representative Name Full name of the authorized representative if different from applicant | Text | No | — | |
| Relationship to Household How is the authorized representative related to or connected to the household? | Text | No | — | |
| Authorization Documentation Describe the documentation provided establishing authority to act for the household (signed statement, power of attorney, court documentation, etc.) | LongText | No | — |
Household Information
| Field | Type | Required | Conditions | Status |
|---|---|---|---|---|
| Household Name Primary name for this household application | Text | Yes | — | |
| Street Address Street address where the household resides | Text | Yes | — | |
| City | Text | Yes | — | |
| State | Text | Yes | — | |
| ZIP Code | Text | Yes | — | |
| County County where the household resides | Text | Yes | — | |
| Phone Number Primary contact phone number for the household | Phone | No | — | |
| Email Address Email address for household communications | No | — | ||
| Total Number of People in Household Total number of people who live together and purchase and prepare meals together | Number | Yes | — | |
| Is anyone in the household 60 years of age or older? | Boolean | Yes | — | |
| Is anyone in the household disabled? Includes anyone receiving disability benefits or unable to work due to disability | Boolean | Yes | — | |
| Does the household have a current mailing address different from the home address? | Boolean | Yes | — | |
| Mailing Address (if different) Complete mailing address if different from home address | LongText | No | When has-different-mailing equals true | |
| Monthly Gross Income (before taxes and deductions) Total monthly gross income for all household members from all sources | Currency | Yes | — | |
| Cash on hand, checking and savings accounts Total liquid resources available to the household | Currency | Yes | — |
Employment and Income
| Field | Type | Required | Conditions | Status |
|---|---|---|---|---|
| Are you currently employed? | Boolean | Yes | — | |
| What is your job title or type of work? | Text | No | — | |
| Employer name | Text | No | — | |
| How many hours per week do you work? Enter the average number of hours you work per week | Number | No | — | |
| What is your gross monthly income from employment? (before taxes and deductions) Include wages, salaries, tips, and commissions before any deductions | Currency | Yes | — | |
| Are you self-employed? | Boolean | Yes | — | |
| What is your net monthly income from self-employment? (after allowable business expenses) Enter your self-employment income after deducting allowable business expenses | Currency | No | — | |
| Do you receive unemployment compensation? | Boolean | Yes | — | |
| Monthly unemployment compensation amount | Currency | No | — | |
| Do you receive Social Security benefits? | Boolean | Yes | — | |
| Monthly Social Security benefits amount | Currency | No | — | |
| Do you receive SSI (Supplemental Security Income)? | Boolean | Yes | — | |
| Monthly SSI amount | Currency | No | — | |
| Do you receive veterans' benefits? | Boolean | Yes | — | |
| Monthly veterans' benefits amount | Currency | No | — | |
| Do you receive any other income? (TANF, General Assistance, pensions, rental income, interest, dividends, child support, etc.) | Boolean | Yes | — | |
| List all other sources of income and monthly amounts Please list each source of income and the monthly amount (e.g., TANF $200, Rental income $500, etc.) | LongText | No | — | |
| What is your total monthly gross income from all sources? This is used for expedited service screening and benefit calculation | Currency | Yes | — |
Resources and Assets
| Field | Type | Required | Conditions | Status |
|---|---|---|---|---|
| Total cash on hand (including money in checking and savings accounts) Include cash, checking accounts, savings accounts, and any other liquid resources available to your household | Currency | Yes | — | |
| Savings certificates, stocks, bonds, or other investments Enter the current value of any savings certificates, stocks, bonds, or other investments | Currency | Yes | — | |
| Value of vehicles owned (exclude one vehicle per adult household member) Enter the fair market value minus any loans owed on vehicles that exceed the state exclusion limits | Currency | Yes | — | |
| Property used for work or self-employment Enter the value of property, tools, or equipment essential to your employment or business | Currency | Yes | — | |
| Other resources not listed above Include any other countable resources such as land that is not your home, additional real estate, etc. | Currency | Yes | — | |
| Do you own your home? Your home and surrounding property are excluded from resource limits | Boolean | Yes | — | |
| Have you received any lump-sum payments in the past 12 months? Include tax refunds, insurance settlements, retroactive Social Security or SSI payments, etc. | Boolean | Yes | — | |
| Describe the lump-sum payment(s) and amount(s) Provide details about each lump-sum payment including source, amount, and date received | LongText | Yes | When lump-sum-received equals true |
Housing and Shelter Costs
| Field | Type | Required | Conditions | Status |
|---|
Medical and Dependent Care Expenses
| Field | Type | Required | Conditions | Status |
|---|
Student and Work Requirements
| Field | Type | Required | Conditions | Status |
|---|
Authorized Representative
| Field | Type | Required | Conditions | Status |
|---|
Rights and Responsibilities
| Field | Type | Required | Conditions | Status |
|---|