Form Dwsp-2303 - Request For Verification - Wisconsin Department Of Children And Families

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STATE OF WISCONSIN
VER
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Family and Economic Security
REQUEST FOR VERIFICATION
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m) Wisconsin Statutes].
Participant Name
Case Number
Date
You must give us verification of the items checked below for each named person so that we can decide if you are eligible to
receive Wisconsin Works (W-2), FoodShare (FS), Child Care Assistance (CC), BadgerCare Plus (BC+), or Medicaid (MA) and
the amount of your benefits or payments. If you do not give us the requested verification by ____/____/____ for W-2, or
____/____/____ for other programs, your application may be denied or your benefits may be reduced or discontinued. If you
need help ask your worker.
Suggested Items to Use for Verification are listed on the back of this form
Program Needed For:
W-2
MA
CC
FS
BC+
Social Security Number for
proof that application
has been made.
Citizenship, Alien Status, Identity, Age for
W-2
MA
CC
FS
BC+
W-2
MA
CC
FS
BC+
Relationship of
to
School Enrollment for
W-2
MA
CC
FS
BC+
W-2
MA
CC
FS
BC+
Residence / Shelter Costs $
Utility Expense $
Gross Earned Income for
W-2
MA
CC
FS
BC+
for the months of
Gross Unearned Income for
W-2
MA
CC
FS
BC+
for the months of
W-2
MA
CC
FS
BC+
Student Loans and Grants for
Assets: savings, checking, life insurance, property,
W-2
MA
CC
FS
BC+
showing value(s) as of _____________________________________________
Vehicles for _____________________________________________________
W-2
MA
CC
FS
BC+
W-2
MA
CC
FS
BC+
Other
_______________________________________________________________
I understand that it is my responsibility to provide the required verification. If I cannot provide it, I must notify my worker, who
may be able to assist me. If I fail to cooperate in obtaining required verification, I understand that my eligibility may be denied or
my benefits may be reduced or discontinued. If I fail to verify an expense I claim, such as child care, rent or utilities, the
expense will not be counted in deciding my eligibility or amount of benefits. I have read and understand this request for
verification.
Participant Signature
Date Signed
Agency Representative Signature
Date Signed
Date Mailed to Participant
RETAIN COMPLETED FORM IN CASE RECORD
DWSP-2303 (R. 01/2009)

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