Example Income Calculation Worksheet (Page 2 of 8) in pdf

SeniorCare Application Instructions

Page 2

F-10076A (09/11)

Applicant and Spouse Information (SECTION I AND II) - SeniorCare enrollment will be based on your income

and your spouse’s income, if your spouse lives with you. If your spouse lives with you, complete the parts of

the application form for you and your spouse, even if your spouse is not requesting SeniorCare. Remember:

The “Spouse Information” portion of the application form needs to be completed only if your spouse lives

with you. Income of other members of your household is not counted for SeniorCare.

Wisconsin Resident

Enrollment in SeniorCare is possible even if you are temporarily living outside the State of Wisconsin if:

•

You have a permanent residence in Wisconsin,

•

You are considered a Wisconsin resident for tax purposes, or

•

You are a registered voter in Wisconsin.

U.S. Citizen

If you (or your spouse living with you) are applying for SeniorCare and are not a U.S. citizen, please enclose a

copy of both sides of your alien registration card to verify your immigration status and alien registration

number.

Race/Ethnicity (Optional)

Shade in the circle that best describes race or ethnic origin of you and your spouse. This information is

voluntary and will not be used to determine your enrollment.

Marital Status and Living Arrangement

If you are not married, shade in the appropriate marital status.

If you are married and your spouse is living with you, shade in the circle next to the appropriate marital status

and shade in the circle next to “Living w/Spouse”.

If you no longer have a spouse living with you, shade in the circle next to “Not Living w/Spouse”.

Social Security Number

Enter your Social Security Number (SSN) and your spouse’s if you are both applying for SeniorCare. If your

spouse is not applying for SeniorCare, you are not required to enter your spouse’s SSN.

The SSN and other personally identifiable information are required by sections 49.688 and 49.82(2) of the

Wisconsin Statutes. Failure to supply the information may result in denial of your application for benefits. The

SSN and personally identifiable information will be used only for the direct administration of the SeniorCare

program. Your SSN permits a computer check of your information with other government agencies such as the

Internal Revenue Service (IRS), Social Security Administration (SSA) and the Department of Workforce

Development (DWD). In addition, the Department will match your name and SSN with a file provided by

health insurance carriers to determine if you have other insurance. If you have a health insurance plan,

SeniorCare will coordinate benefit coverage with your plan.

Mailing Address (SECTION III)

Address

Print the address where you would like information regarding your SeniorCare enrollment to be sent. This may

be your current address OR the current address of your representative, legal guardian or power of attorney.

Example Income Calculation Worksheet Page 2