APP
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
REQUEST FOR REPLACEMENT FOODSHARE BENEFITS
INSTRUCTIONS: If you are a current FoodShare member and food you purchased with FoodShare benefits was
destroyed due to a household misfortune or natural disaster, complete this form and submit it, along with proof* that your
food was destroyed, using one of the following options:
Note: Completed form and proof must be submitted within 10 days of the loss.
Online
Scan all pages of the form to the ACCESS website. You
can do this through your ACCESS account, which you can
log into at access.wi.gov
.
Mail
If you live in Milwaukee County, mail the form to:
MDPU
PO Box 05676
Milwaukee, WI 53205
If you do not live in Milwaukee County, mail the form to:
CDPU
PO Box 5234
Janesville, WI 53547
Fax
• If you live in Milwaukee County, fax the form to
888
-409-1979.
• If you do not live in Milwaukee County, fax the form t
o
855
-293-1822.
In Person
Take the form to your agency. Your agency contact
information is on the Wisconsin Department of Health
Services (DHS) website at
www.dhs.wisconsin.gov/
forwardhealth/imagency/index.htm
Name – Member (Last, First, Middle Initial)
Describe how your food was destroyed (for example, flooding, power outage, fire):
of Destroyed
Food
$
Date Food Was Destroyed (this may be different than the date of household misfortune or natural
disaster that destroyed the food. For example, if your power went out, food was most likely destroyed
or spoiled the following day. A fire or flood may have destroyed food the same day.)
I understand the questions and statements on this 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 documents to prove what I have said. I understand that the local
agency may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits.
*Acceptable forms of proof can include information provided by the fire department, the police, a community organization,
or other sources of help. Proof of destroyed food might not be needed when a state of emergency has been declared.
Fair Hearings: I understand I have the right to file a fair hearing request to appeal any action taken concerning my
application or ongoing benefits if I do not agree with that action. I understand I can ask for a fair hearing by writing to:
Department of Administration, Division of Hearings and Appeals, PO Box 7875, Madison, WI 53708-7875 or by
calling 608-266-7709. I may also contact the agency office where I applied and ask for a fair hearing verbally or in writing.
I understand I can refer to the ForwardHealth Enrollment and Benefits handbook (P-00079) for more information.
