INCOME MAINTENANCE PRESENTATION REQUEST
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Questions regarding this request form should be directed to Carol Cole at
colecj@dhfs.state.wi.us.
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1
. What are you requesting?
What are you requesting?
Materials
Speaker
Technical Assistance
Training
Other
2
. If other, please describe.
If other, please describe.
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3
. For which topics are you making this request?
For which topics are you making this request?
ACCESS
BadgerCare
CARES Worker Web
Caretaker Supplement
Family Care
Family Planning Waiver Program
FoodShare Wisconsin
Medicaid
SeniorCare
Wisconsin Funeral and Cemetery Aids Program
Other
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4
. Which agency or organization do you represent?
Which agency or organization do you represent?
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5
. What type of agency is this?
What type of agency is this?
Local County/Tribal
Community Based Organization
Professional Organization
Other
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6
. Is there a specific date by which you need this information?
Is there a specific date by which you need this information?
Yes
No
7
. What is the date by which you need this information?
What is the date by which you need this information?
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8
. Is this for a specific event?
Is this for a specific event?
Yes
No
9
. If yes, what is the event?
If yes, what is the event?
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10
. What is the size ot the intended audience?
What is the size ot the intended audience?
1 - 10
11 - 20
21 - 40
41 - 60
61 - or more
11
. Is there anything else you feel we should know about this request, your agency, or your event?
Is there anything else you feel we should know about this request, your agency, or your event?
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12
. How we can contact you? Please give us your name, telephone number, and email address.
How we can contact you? Please give us your name, telephone number, and email address.
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