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Get WI F-10076 2008

Return completed application form and fee to SeniorCare P. O. Box 6710 Madison WI 53716-0710 If you have questions contact SeniorCare Customer Service Hotline at 1-800-657-2038. ROUND INCOME TO THE NEAREST DOLLAR -- DO NOT INCLUDE CENTS SPOUSE APPLICANT If Living with Applicant Gross Social Security Gross Wages Interest Dividends and Capital Gains Net Self-Employment Income Retirement Income Other Income Grand Total SECTION V - SIGNATURE Required I understand the questions and statements on this application form. I understand the penalties for giving false information or breaking the rules as outlined in the rights and responsibilities section of the SeniorCare application instructions. 688 Wis. Stats. New Application Select One Add Spouse SECTION I - APPLICANT INFORMATION Are you requesting SeniorCare Race/Ethnicity Optional Choose all that apply Wisconsin Resident U.S. Citizen American Indian/Alaskan Native Hawaiian/Other Pacific Islander Black/African American White Asian Hispanic Ethnicity Gender Male Female Current Marital Status Married Divorced Widowed Separated Single Last Name If Married or Separated are you Middle Initial First Name / Birth Date Living with Spouse - Soc. Sec. No. Not Living with Spouse SECTION II - SPOUSE INFORMATION IF LIVING WITH APPLICANT SECTION III - MAILING ADDRESS Apartment Street State City Telephone Address is Same as residence Zip Code Different than residence Your Authorized Representative s / Legal Guardian s / Power of Attorney s address SECTION IV - EXPECTED ANNUAL INCOME Required For each item below enter the total gross before deductions expected ANNUAL income for you and your spouse for the next twelve months. DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10076 10/08 Yes No Prefiere las notificaciones en espa ol APPLICATION STATE OF WISCONSIN Section 49. I certify under penalty of perjury and false swearing that all my answers are correct and complete to the best of my knowledge including information provided about the citizenship or immigration status of my spouse and myself* I understand and agree to provide documents to prove what I have said* I understand that the agency may contact other persons or organizations to obtain the necessary proof of my eligibility and benefits. SIGNATURE - Applicant or Representative Signature of Applicant Authorized Representative PRINTED NAME - Applicant or Representative Legal Guardian Two witness signatures are required only if you sign with an X Witness 1 Power of Attorney / Durable Power of Attorney SECTION VI - ENROLLMENT FEE Required Enrollment Fee Enclosed 30 - One Applicant 60 - Two Applicants Make check or money order payable to State of Wisconsin Include names of all applicants on payment. I certify under penalty of perjury and false swearing that all my answers are correct and complete to the best of my knowledge including information provided about the citizenship or immigration status of my spouse and myself* I understand and agree to provide documents to prove what I have said* I understand that the agency may contact other persons or organizations to obtain the necessary proof of my eligibility and benefits. SIGNATURE - Applicant or Representative Signature of Applicant Authorized Representative PRINTED NAME - Applicant or Representative Legal Guardian Two witness signatures are required only if you sign with an X Witness 1 Power of Attorney / Durable Power of Attorney SECTION VI - ENROLLMENT FEE Required Enrollment Fee Enclosed 30 - One Applicant 60 - Two Applicants Make check or money order payable to State of Wisconsin Include names of all applicants on payment. .

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