Applicant name: Izabella D Johnson

Your tracking number: 9613363695

This document includes personal information that you may want to keep private. Keep this in
mind if you are printing or sharing this document. Make sure you keep the document somewhere
private and safe.

Your application
These are the answers you gave on your application. You should keep this document for
your records.

You submitted your application on September 23, 2024 at 07:34 PM Central Time. You’ll get
a decision about your application within 30 days of the program filing date.

Filing Date

In most cases, your filing date is the day you sign and submit your online application.

For FoodShare, Wisconsin Shares Child Care, Wisconsin Works (W-2), and Job Access Loan
(JAL), if you submit your application after 4:30 p.m. or on a weekend or holiday, your filing
date is the next business day.

For FoodShare, your filing date is the date that your benefits will begin if your application is
approved.

For Family Planning Only Services, health care, and Caretaker Supplement benefits, your
filing date will be the day your application is submitted to the agency, and your benefits will
begin the first day of the month if your application is approved.

For example, if your filing date is April 29th, your benefits will begin April 1st.

Programs you applied for

Program name Household members

Health care insurance through BadgerCare Izabella D Johnson

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Plus or Medicaid

Your agency contact information

Your income maintenance agency
This agency will review your application and/or manage your Health care insurance through
BadgerCare Plus or Medicaid applications. Your agency will make a decision about your case
within 30 days from your filing date.

Dane County Job Center

1819 Aberg Ave.
Madison, WI 53704
(888) 794-5556

Documents for proof that we need

We may need to see documents to verify the answers on your application. If so, we’ll let you know.
It might be helpful to have documents that prove your ID, your address, your income, and your bills
ready.

Your application details

Here’s what you told us in your application. Important information about your rights and
responsibilities is also listed below.

Your information

Tell us about yourself

Question Your answer

Name Izabella D Johnson

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Date of birth 8/17/2005

Social Security number 389-27-3630

More about you

Question Your answer

Marital Status Never married

Sex Female

Ethnicity Not Hispanic or Latino/a

Race White

White details I don't know

Are you a tribal member or a child or No

grandchild of a tribal member?

Your residence

Question Your answer

Do you live in Wisconsin? Yes

Do you plan to keep living in Wisconsin? Yes

What county do you live in? Dane

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Do you live on tribal lands? No

Are you a migrant worker? I don't know

Are you currently homeless? No

Have you been homeless in the past 12 No

months?

Where you live

Question Your answer

Where are you currently living? Someone else's home

Someone else’s residence Other

Your physical address 3105 county highway p

House
Mount horeb, WI 53572

Your contact information

Question Your answer

What is the primary language spoken in your English

home?

Is this your preferred language? Yes

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Primary phone number 608-937-9590
Home

Phone Number #2 Not answered

Phone Number #3 Not answered

If you don’t have a phone or we can’t reach No

you at the number above, do you have a
different phone number where we can leave
a message for you?

What’s the best way to contact you during Home phone

the week?

What’s the best time of day to call you? Late afternoon

If you are deaf or hard of hearing, what Neither of these

service or device do you use?

Do you want to get text messages about your Not answered

application if your agency is able to do text
messaging?

Email address izzybb05@gmail.com

Re-enter email address izzybb05@gmail.com

Do you want to view most of your letter Yes

online instead of getting them by mail?

Do you want to get emails about your health Yes

care services from our health care partners?

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 People in your household

Your household

Question Your answer

Name Izabella D Johnson

Name Odin R Johnson

Name Luther M Johnson

Name Megin S Swearingen

Do you have any children in foster care or No

kinship care who live outside the home but
will return?

Household relationships

Question Your answer

Izabella D Johnson is the daughter of Luther M Johnson

is the sister of Odin R Johnson
is the not related of Megin S Swearingen

Odin R Johnson is the not related of Megin S Swearingen

Luther M Johnson is the father of Odin R Johnson

is the not related of Megin S Swearingen

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More about Odin

Question Your answer

Name Odin R Johnson

Sex Male

Date of birth 8/21/2004

Social security number Not answered

Marital Status Never married

Ethnicity I don't know

Race White

White details I don't know

Is Odin a tribal member or a child or

No
grandchild of a tribal member?

Does Odin live in Wisconsin? Yes

Is Odin a migrant worker? I don't know

Has Odin been homeless in the past 12 No

months?

Where is Odin currently living? My home

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What is Odin’s preferred language? English

More about Luther

Question Your answer

Name Luther M Johnson

Sex Male

Date of birth 7/27/1978

Social security number Not answered

Marital Status Married

Ethnicity Not Hispanic or Latino/a

Race I don't know

Is Luther a tribal member or a child or

No
grandchild of a tribal member?

Does Luther live in Wisconsin? Yes

Does Luther plan to keep living in No

Wisconsin?

Is Luther a migrant worker? I don't know

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Has Luther been homeless in the past 12 I don't know
months?

Where is Luther currently living? My home

What is Luther’s preferred language? English

More about Megin

Question Your answer

Name Megin S Swearingen

Sex Female

Date of birth 1/26/2005

Social security number Not answered

Marital Status Never married

Ethnicity I don't know

Race White

White details Other

Is Megin a tribal member or a child or

No
grandchild of a tribal member?

Does Megin live in Wisconsin? Yes

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Does Megin plan to keep living in Wisconsin? Yes

Is Megin a migrant worker? I don't know

Has Megin been homeless in the past 12 I don't know

months?

Where is Megin currently living? My home

What is Megin’s preferred language? English

Pregnancy

Question Your answer

Is anyone in your household pregnant? No

Tax Filer

Question Your answer

Is anyone in your household planning to file Yes

federal income taxes for 2024?

Who is planning to file? Izabella Johnson

Odin Johnson
Luther Johnson
Megin Swearingen

Izabella’s tax filer details

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Question Your answer

Is Izabella being claimed as a dependent on No

federal income taxes by someone outside
the household?

Is Izabella planning to claim any dependents No

on their federal income taxes?

Odin’s tax filer details

Question Your answer

Is Odin being claimed as a dependent on No

federal income taxes by someone outside
the household?

Is Odin planning to claim any dependents on No

their federal income taxes?

Luther’s tax filer details

Question Your answer

Is Luther planning to jointly file federal No

income taxes with their spouse?

Is Luther being claimed as a dependent on No

federal income taxes by someone outside
the household?

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Is Luther planning to claim any dependents No
on their federal income taxes?

Megin’s tax filer details

Question Your answer

Is Megin being claimed as a dependent on No

federal income taxes by someone outside
the household?

Is Megin planning to claim any dependents No

on their federal income taxes?

Household details

Citizenship information

Question Your answer

Are all household members U.S. citizens? Yes

Your health

Question Your answer

Does anyone in your household need help

No
with activities of daily living?

Has anyone in your household been No

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diagnosed with tuberculosis?

Has anyone in your household been in an

No
accident in the last three months?

Has anyone in your household had a medical

Not answered
emergency in the last three months?

Medicare coverage

Question Your answer

Is anyone in your household getting or able

No
to get Medicare Part A or Part B?

FoodShare Basic Work Rules/Work Requirement Information

Question Your answer

Is anyone in your household in a Wisconsin

Not Answered
Works (W-2) work program?

Is anyone in your household responsible for

caring for a child under age 6 who does not Not Answered
live with you?

Is anyone in your household responsible for

caring for another person who cannot care Not Answered
for themselves?

Is anyone in your household a veteran? A

veteran is defined as a person who served in
Not Answered
the United States Armed Forces (the Army,
Marine Corps, Navy, Air Force, Space Force,

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Coast Guard, National Guard, or Armed
Forces Reserve) who has been discharged
or released under any condition.

Is anyone in your household an 18–24-year-

old who was in foster care, a subsidized
Not Answered
guardianship, or court-ordered kinship care
when they turned 18?

Is anyone in your household participating in a

work program? Work programs provide
education, training, and other supportive Not Answered
services to job seekers looking to gain new
or different employment.

Income

Work and volunteer activities

Question Your answer

Does anyone in your household have work No

activities?

Other household income

Question Your answer

Does anyone in your household have other No

income?

Other benefits

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Question Your answer

Is anyone getting grants, scholarships, or No

other aid for education or training?

Has anyone gotten an SSI approval letter, No

but not yet gotten a payment?

Is anyone getting Medicaid benefits through No

SSI 1619(b)?

Izabella's annual income

Question Your answer

What do you expect Izabella’s total income I don't know

will be in 2024? This should be the gross
income, which is the amount of money you
get before taxes and other deductions are
taken out.

Other Bills

Question Your answer

Does anyone in your household have tax No

deductions?

Health Insurance

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Health insurance policy holders

Question Your answer

Does anyone have a health insurance policy

that covers one or more people in your No
household?

Health care rights and responsibilities

Below are the rules for the BadgerCare Plus and Medicaid health care coverage programs
and the Family Planning Services Only program. Please read the following information
carefully. These programs have a unique set of rights and responsibilities. You’ll be able to
save a copy after you submit your application.

Your rights
Every health coverage applicant or member has the right to:

· Be treated with respect by agency staff.

· Have your civil rights upheld.
· Have your private information kept private.
· Get an application or renewal or have the application or renewal mailed on the same
day you ask for it.
· File an application or renewal on the day of initial contact.
· Get a decision about your application or renewal within 30 days of the day the agency
got it. If your application or renewal is received at the agency after 4:30 p.m. or on a
weekend or holiday, the date of receipt will be the next working day. This includes
paper and online applications or renewals.
· Be told in advance if your benefits are going to be reduced or ended and the reason for
the change.
· Ask the agency to explain anything in this application or renewal or other materials that
you do not understand.
· Request a fair hearing if you disagree with any action of the agency.
· See the agency's records and files relating to you except information obtained from a
confidential source.
· Ask for an interpreter or for information explained to you in your own language or for

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 help if you need help accessing our programs or need this material in a different format
because of a disability.
· Get emergency medical care.
· Remain enrolled, even if temporarily absent from the state, as long as you are still a
Wisconsin resident.

More information is in the Enrollment and Benefits Handbook, which will be mailed or emailed
to you.

Fair hearing
You have the right to a fair hearing if you do not agree with any action taken regarding your
application or renewal or your ongoing benefits. You may request a fair hearing by writing to:

Department of Administration
Division of Hearing and Appeals
P.O. Box 7875
Madison, WI 53707-7875

You may also contact the agency where you applied and ask for help with filing a fair hearing
request. More information about fair hearings is in your “About Your Benefits” letter and the
Enrollment and Benefits Handbook.

Your responsibilities
Reporting changes
You can report changes through your ACCESS account, by calling or visiting your agency or
by completing and submitting the following form:

· Information Change Report (BadgerCare Plus or Family Planning Only Services)

· Wisconsin Medicaid Change Report

You must report to the agency any of the changes listed below:
For health care coverage through BadgerCare Plus or Medicaid, report to the agency within
10 days any changes in:

· Income of any household member.

· Employment of any household member (beginning or ending, part time to full time).

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 · Address.

· Anyone moving in or out of your home, someone becoming pregnant or giving birth,
someone getting married or divorced, or your living arrangement changing (for
example, someone goes into a nursing home or other institution).

· Health insurance.

· Assets (only if your household receives Medicaid for the Elderly, Blind, or Disabled).

· Housing bills, utility bills, medical expenses, or other allowable expenses (only if your
household receives Medicaid for the Elderly, Blind, or Disabled).

For Family Planning Only Services, you only need to report within 10 days if:
· You move to a new address or out of state.

· Your living arrangement changes (for example, incarceration).

Use of Social Security number/privacy statement

Personally identifiable information, including Social Security numbers (Social Security
numbers), will be used for the direct administration of the health care programs in which you
participate. Providing information on U.S. citizenship and Social Security number is
voluntary; however, any person who wants health care but does not provide this information
will be denied benefits. The collection of a Social Security number for each person applying
for or getting benefits is authorized under Wis. Stat. § 49.82(2). Social Security numbers, as
well as other information provided, are used for verification with the Internal Revenue
Service, Social Security Administration, Unemployment Insurance Division, School Lunch
Program, and Department of Transportation. Social Security numbers are also used to check
the identity of household members to prevent duplicate participation and to make sure the
household meets enrollment rules.

If you are applying only for emergency services because of your immigration status or you
are a pregnant woman applying for BadgerCare Plus Prenatal Services, you do not need to
provide Social Security number information. For a health care application or renewal, you do
not need to provide a Social Security number or apply for one for your infant if you were

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enrolled in a health care program when you gave birth.

Your Social Security number will not be shared with U.S. Citizenship and Immigration
Services (USCIS).

Computer check verification/computer matching

Information collected on the application or renewal may be verified through computer
matching programs and will also be used to monitor compliance with program rules and
program management.

The Income and Eligibility Verification System and other computer matching are used to verify
information with agencies such as the Internal Revenue Service, Social Security
Administration, Unemployment Insurance Division, and Department of Transportation. The
agency may also submit this information to USCIS and other agencies for verification.

The county or tribal agency, the Department of Health Services, and the Department of
Children and Families are authorized under Wisconsin law to request any information that is
appropriate and necessary for the proper administration of programs. By applying, you are
authorizing any person, including any financial institution, credit reporting agency, employer,
or educational institution, to release this information. This authorization remains in effect until
your application or renewal is denied or your enrollment ends.

Immigration status
All people living in your household who are applying for benefits must be U.S. citizens,
nationals, or qualifying immigrants to get benefits. The immigration status of any person in
your household who is applying for benefits will be verified with USCIS. Information from
USCIS may affect your household's enrollment and benefit amount. Immigration status will
not be verified with USCIS for people who are not applying for benefits, but their income and
contributions may be counted.

Other health care coverage

As a condition of health care enrollment, you must report to the agency any third party who

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may be liable to pay for medical care for you and your family. You must cooperate by giving
information as requested. This also includes any insurance that may be available through an
absent parent or an employee's group health insurance.

Your enrollment in health care benefits gives the state the right to collect medical support
payments for medical expenses that are covered by BadgerCare Plus and/or Medicaid.
Medical support payments include those made under a court order and/or by an insurer.

The state has the right to use part of the medical support to pay back the cost of health care
benefits you receive. The medical support payments kept by the state cannot be more than
the total amount of health care benefits you receive through BadgerCare Plus and/or
Medicaid. If you no longer receive health care benefits, the state has the right to collect
medical support payments on past-due medical expenses that were covered by BadgerCare
Plus and/or Medicaid.

Recovery of health care

Wisconsin state law provides for the recovery of certain health care benefits you get while
age 55 or older and residing in the community. With certain exceptions, the law also provides
for the recovery of all health care benefits you get while you are a resident in a nursing home
or an inpatient in a hospital for 30 days or more. A lien may be placed on your home for
benefits you receive while in a nursing home if you are unlikely to return home and your
spouse, minor child, or disabled child does not live in the home.

Federal health insurance Marketplace

If you do not meet the rules to enroll in BadgerCare Plus and/or Medicaid, the agency may
send your information to the federal health insurance Marketplace. The Marketplace will use
this information to see if you can get help with paying for private health insurance.

Nondiscrimination notice: Discrimination is against the law

The Wisconsin Department of Health Services complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color, national origin, age, disability, or
sex. The Department of Health Services does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.

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The Department of Health Services:
Provides free aids and services to people with disabilities to communicate effectively
with us, such as:
o Qualified sign language interpreters.
o Written information in other formats (large print, audio, accessible electronic
formats, other formats).
Provides free language services to people whose primary language is not English,
such as:
o Qualified interpreters.
o Information written in other languages.
If you need these services, contact the Department of Health Services civil rights coordinator
at 844-201-6870.

If you believe that the Department of Health Services has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability, or
sex, you can file grievance with: Department of Health Services, Attn: Civil Rights
Coordinator, 1 West Wilson Street, Room 651, PO Box 7850, Madison, WI 53707-7850, 844-
201-6870, TTY: 711, fax: 608-267-1434, or email to dhscrc@dhs.wisconsin.gov. You can file
a grievance in person or by mail, fax, or email. If you need help filing a grievance, the
Department of Health Services civil rights coordinator is available to help you.

You can also file a civil rights complaint with U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, or by mail or phone at:
U.S Department of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201
800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

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Acknowledgement
By signing the application or renewal, you are authorizing your agency, the Wisconsin
Department of Health Services, and the Wisconsin Department of Children and Families to
request any information that is appropriate and necessary for the proper administration of the
program under Wisconsin law. Anyone, including financial institutions, credit reporting
agencies, or educational institutions may release this information, unless it is prohibited or
restricted by law. Your authorization remains in effect until (1) your application or renewal is
denied, (2) your eligibility ends, or (3) you inform your agency in writing that you wish to end
your authorization.

Also, your signature on the application or renewal means that you understand the questions
and statements on this application/renewal form and the penalties for giving false information
or breaking the rules. By signing the application/renewal, you are certifying under penalty of
perjury and false swearing that all of your answers are correct and complete to the best of
your knowledge, including information provided about the citizenship and immigration status
of each household member applying for benefits. Also, you understand and agree to provide
documents to prove what you have said.

By checking this box, I attest that I have read and understand the rights and responsibilities
on this screen.

Good cause notice

Please read the following information about claiming good cause for not cooperating with
child support. You can download this notice for your records.

To get child care, health care, Caretaker Supplement (CTS), Wisconsin Works (W-2) and/or
Job Access Loan assistance, you are required by law to cooperate with your county, tribal
human/social services, W-2 and child support agencies. You must cooperate in getting any
support (financial or medical) owed to you and your children. (You may not have to cooperate
for some children, depending on their age and which benefits you have requested for them.)
The eligibility of children and pregnant women for health care is not affected if you fail to
cooperate.

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Cooperation means that you may have to do one or more of the following:
· Name the absent parent of any child included in your application for child care, health
care, or CTS and give information to help find that parent.
· Help to legally identify the absent parent of any child for whom child care, health care,
or CTS is requested or received.
· Help to obtain money or property owed to you or the children who receive child care,
health care, W-2, or CTS.
· Attend required court hearings and agency appointments, including appointments for
genetic testing.
· Report to your worker or child support agency any court ordered child support paid
directly to you by the absent parent.
· Identify and provide information to help the State pursue any third party who may be
liable to pay for medical care and services.

Your cooperation is important because it may help you and your children:
· Find the absent parent.
· Legally establish the identity of your child's absent parent.
· Become eligible for Social Security, Veterans Benefits, or other government benefits in
the future.
· Receive adequate child or medical support payments or both to end your need for child
care, W-2, or health care benefits.

You may have a good reason for not cooperating. The following are circumstances under
which your agency may find that you have "good cause" for not cooperating:
Your cooperation could result in physical and/or emotional harm to your child,
including child kidnapping;
Your cooperation could result in physical and/or emotional harm to you, including
domestic abuse;
Your cooperation with the child support agency would make it more difficult for you to
escape domestic abuse or risk further domestic abuse;
Your child was born as a result of incest or sexual assault;
A petition for the adoption of your child has been filed with a court or;
You are working with an agency that is helping you to decide whether you will place
your child up for adoption.

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If you want to claim good cause for not cooperating with the child support agency, tell your
worker. You will be given a claim form which explains how to claim good cause. You may
also ask for the claim form to help you decide whether or not to claim good cause for not
cooperating. The claim may be requested or submitted at any time.

When there has been a determination that you are not cooperating with the child support
agency, you will need to either submit a timely good cause claim or cooperate with the child
support agency, or you may lose your benefit(s).

If your claim of good cause for not cooperating with the child support agency is denied, you
will not be eligible for child care, W-2, Job Access Loans, health care, or CTS unless you
begin to cooperate. If you are receiving health care, your children may still be eligible. The
county or tribal human/social services and child support agencies will continue in the effort to
obtain any financial and medical support for the children who are getting health care.

If you are receiving W-2 services and you do not agree with the "good cause" claim decision,
you may request a fact-finding review by contacting your W-2 Agency within 45 days of the
decision date.

If you are receiving child care, health care, or CTS, and you do not agree with the good
cause claim decision, you may request a Fair Hearing by writing to the Department of
Administration, Division of Hearings and Appeals within 45 days of the decision date.

I have read this information and I understand that I have the right to claim good cause for not
cooperating with child support.

Submit your application

I have agreed to submit this application by electronic means. By signing this electronically, I
certify under penalty of perjury and false swearing that my answers are correct and complete
to the best of my knowledge, including information provided about the citizenship or
immigration status for each household member applying for benefits. I also certify that:
· I understand the questions and statements on this application.
· I have read and understand my rights and responsibilities on the previous [page/pages]
· I understand the penalties for giving false information or breaking the rules.
· I understand that the agency may contact other people or organizations to obtain
needed proof of my eligibility and level of benefits.

I understand that by checking this box and typing my name below, I am providing my
electronic signature. I understand that an electronic signature has the same legal effect and

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can be enforced in the same way as a written signature.
Izabella D Johnson

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