Back-Up Applicant/Participant Signature
Document Number: DWSP-11154
Description: This is a multiple program form for the following programs: Wisconsin Works (W-2), Child Care Assistance, FoodShare and Medicaid. The form is only to be used for a signature when a printer is unavailable to print the Combined Application Form (CAF) after the completion of the interactive interview. The form must be signed in the presence of an agency representative.
Document Attachments:
DWSP-11154 (English Print Version - pdf/18 KB)
DWSP-11154-H (Hmong Print Version - pdf/20 KB)
DWSP-11154-S (Spanish Print Version - pdf/18 KB)
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