Example Income Calculation Worksheet (Page 5 of 8) in pdf

Example Income Calculation Worksheet Page 5

SeniorCare Application Instructions

Page 5

F-10076A (09/11)

To see if you might be able to get health, nutrition and other programs, contact your local county or tribal

agency or visit access.wi.gov. This is an internet tool that will ask between 6 and 25 questions and will take

about 15 minutes. Once you are done, ACCESS will tell you if you might be able to get health, nutrition and

other programs and how to apply.

YOUR RIGHTS AND RESPONSIBILITIES

Changes such as death, mailing address, change in permanent residence outside of Wisconsin and household

composition changes (marriage/divorce/separation) that affect you and/or your spouse must be reported to the

SeniorCare Customer Service Hotline at 1-800-657-2038 within 10 days.

Your signature on the application (Section V on this form) means that you authorize the Wisconsin Department

of Health Services to request any additional information that is appropriate and necessary for the proper

administration of the SeniorCare program.

By signing your name or by signature of a person signing on your behalf, you agree that information given by

you or your representative is true and correct. You and your representative are responsible for incorrect

information or errors. Penalties for providing fraudulent information could be a fine of not more than $10,000

or imprisonment of not more than one year, or both.

You have the right to request a fair hearing if you do not agree with any action taken concerning your

application or ongoing benefits. You may request a fair hearing by writing to:

Wisconsin Department of Administration

Division of Hearings and Appeals

P.O. Box 7875

Madison, WI 53707-7875

The Department of Health Services is an equal opportunity employer and service provider. If you have a

disability and need to access this information in an alternate format, or need it translated to another language,

please contact (608) 266-3356 or (888) 701-1251 TTY. All translation services are free of charge.

To file a complaint of discrimination, contact:

Civil Rights Compliance Office

Wisconsin Department of Health Services

Office of Affirmative Action and Civil Rights Compliance

1 W. Wilson Street, Room 561

P.O. Box 7850

Madison, WI 53707-7850

Telephone (608) 266-9372 (Voice) or (888) 701-1251 (TTY) or FAX (608) 267-2147

Example Income Calculation Worksheet Page 5