Notice: While unemployment insurance payments have not been impacted by the federal government shutdown at this time, November benefits for FoodShare members have been reduced due to the ongoing shutdown. For questions about using FoodShare benefits, information about benefit delays, or help finding food assistance resources, visit:
Wisconsin Department of Health Services' FoodShare webpage
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Document Number: WKC-17876-E
Description: This form is used for meeting the reporting requirements per s. DWD80.02 (2)(k) Wisconsin Administrative Code.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). We are also providing a PDF (WKC-17876) which you can print and complete by hand.
Content Contact: Lynn Weinberger
Document Attachments:
WKC-17876-E (Electronic Version - Word/62 KB)
WKC-17876 (Print Version - pdf/105 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
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