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CDPU
CENTRALIZED DOCUMENT PROCESSING UNIT
PO BOX 5234
JANESVILLE WI 53547 5234
State of Wisconsin
Mailing Date: 03/19/2015
000310
BRIAN SCHOENBECK
602 ROOSEVELT DR
WEST BEND WI 53090 1526
Case#: 8136698481
Notice of Proof Needed
To get or keep FoodShare and BadgerCare Plus benefits you need to provide proof of items by the due
date listed below. The items that need proof are listed on the next page along with examples and
instructions. If you do not provide the proof by the due date, benefits will be denied, decreased, or ended.
To make sure your benefits get processed as quickly as possible, use the Document Tracking Sheet at the
end of this notice.
Program(s)
Due Date
Contact Information
FoodShare; BadgerCare
Plus
Mar. 30, 2015
Moraine Lakes Consortium
Toll Free Number: 1-888-446-1239
Fax Number: 1-855-293-1822
You can use the fax number above to
send proof or to report changes
Case : 8136698481
Date : 03/19/2015
Page 01 of 10
Proof Needed
This section lists items that we need proof of by the due date listed below. Contact us right away if
you have questions or problems getting the proof and we will help you.
What?
Who?
Employment at BRIAN
SEEK INC
including :
Date job ended,
date when last
paycheck will
be received
and amount of
last paycheck;
Expected
monthly income
before taxes or
deductions and
number of
hours worked
per pay period;
Expected
monthly income
before taxes
and any pre-tax
deductions
including how
much and how
often
Employment at
QPS
including :
Expected
BRIAN
Case : 8136698481
Examples*
Pay Stubs from the
last 30 days; enclosed
Employer Verification
of Earnings form filled
out and signed by your
employer; or statement
from your employer
with the same
information.
Pay Stubs from the
last 30 days; enclosed
Employer Verification
of Earnings form filled
Date : 03/19/2015
Program(s)
FoodShare;
BadgerCare
Plus
Due Date
Mar. 30, 2015
FoodShare;
BadgerCare
Plus
Mar. 30, 2015
Page 02 of 10
monthly income
out and signed by your
before taxes or
employer; or statement
deductions and
from your employer
number of
with the same
hours worked
information.
per pay period;
Expected
monthly income
before taxes
and any pre-tax
deductions
including how
much and how
often
*If you do not have any of the examples of proof listed, there are other things you can use.
For a complete list of examples, go online to dhs.wi.gov/em/customerhelp or contact us.
Case : 8136698481
Date : 03/19/2015
Page 03 of 10
Case : 8136698481
Date : 03/19/2015
Page 04 of 10
STATE OF WISCONSIN
EVFE
EMPLOYER VERIFICATION OF EARNINGS
MUST BE COMPLETED BY THE EMPLOYER (Instructions on the back)
Please return this form by : 2015-03-30
Please return this form to:
CENTRALIZED DOCUMENT PROCESSING UNIT
PO BOX 5234
JANESVILLE WI 535475234
EMPLOYEE INFORMATION
BRIAN SCHOENBECK
EMPLOYER INFORMATION
SEEK INC
FEIN:
Section 1 – EMPLOYMENT STATUS
Is the employee listed above currently employed by your company?
Yes
No
If yes, complete Section 2.
If “no”, Indicate employment end date: ____/____/________
Reason employment ended:
Never employed
Laid Off
Date of final paycheck: ____/____/________
Start date of employment:
Employee Type:
Quit
Strike
Fired
Other
Gross pay for final month: $
Section 2 – EMPLOYMENT INFORMATION
____/____/________
Date first paycheck received: ____/____/________
Temporary
Permanent
Title:
Manager
Other
Please provide an estimate of the following wage information for the next 30 days.
Type of Pay
Best Estimate of
Weekly Hours
Regular:
Overtime:
Other Shift Pay:
Weekend/Shift Differential Pay:
Holiday Pay:
Other:
Salary if not paid hourly:
Bonus and/or Commissions:
Cash and/or Tips:
Frequency of Pay:
Weekly
Rate of Pay
Per Hour
Regular Scheduled
Work Hours
$
$
$
$
$
$
Gross Per Pay Period
$
$
$
Bi-Weekly
Semi-monthly
Monthly
Irregular
Section 3 – PRE-TAX DEDUCTION INFORMATION
Does the employee have any of the following pre-tax deduction?
Type
How much is deducted?
Health insurance premiums:
$
Health care savings accounts:
$
Parking and transit costs:
$
Group life insurance premiums:
$
Retirement contributions:
$
Flexible savings accounts for child care or other dependent care:
$
Employer / Designee Signature:
Print Name:
Title:
How often?
Date: ____/____/________
Phone:__________________
FAX:____________________
Employer Comments
Worker(s):
Moraine Lakes Consortium
Case : 8136698481
Date : 03/19/2015
Page 05 of 10
EMPLOYER VERIFICATION OF EARNINGS INSTRUCTIONS
The Department of Children and Families, the Department of Health Services, a county child support agency or a county
department under s. 46.215, 46.22, or 46.23, a multicounty consortium, a Wisconsin Works (W-2) agency, or a tribal governing
body may request from any person in this state information it determines appropriate and necessary for determining or verifying
eligibility or benefits for a recipient under any income maintenance program, W-2, Child Support enforcement or Wisconsin
Shares. Unless access to the information is prohibited or restricted by law, or unless the person has good cause, as determined by
the departments in accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort
to provide the information within 7 days after receiving a request under this paragraph.
We require employment and wage information concerning the employee named on this Employer Verification of Earning form.
Complete and return the form to the employee as soon as possible so that s/he can return it by the date indicated.
- Review the Federal Employment Identification Number (FEIN) listed on the form. If it is incorrect or missing, write the correct
number on the form, if know.
- This form will be scanned. Write clearly using blue or black ink.
- Write additional comments in the comments section.
Although it is the employee’s responsibility to return this form to the local agency, in order to expedite this process, you may
return this form to the address or fax number if listed. If you do, inform the employee that you have returned this form.
Section 1 – EMPLOYMENT STATUS
If the employee never worked for your company, check the “Never Employed” box. Sign, date and return the form. If the employee
listed on the form is no longer an employee of your company, check the “No” box. Write in the date the employment ended.
Indicate the reason employment ended. Write in the date of the employee’s last paycheck and gross amount (before any
deductions) of pay for his/her final month.
Section 2 – EMPLOYMENT INFORMATION
If the employee listed on the form is employed by your company, check the “Yes” box and complete Section 2. Write in the date
the employee started working for your company and the date of the employee’s first check.
Type of Pay – Provide your best estimate of gross wages (before any deductions) the employee will earn for the next 30 days.
Best Estimate of Weekly Hours – Provide the hours the employee is expected to work weekly.
Rate of Pay Per Hour – If the type of pay is regular, holiday, other shift, overtime, weekend or other type of pay, indicate the
rate of pay the employee earns per hour.
Regularly Scheduled Work Hours – Indicate the employee’s regularly scheduled hours and the days worked (i.e. 8:00 a.m. to
4:30 p.m. Monday, Tuesday, Wednesday and Saturday).
Gross Per Pay Period – If the employee’s type of pay is salary, bonus, commissions, cash and/or tips, write in the gross amount
(before any deductions) the employee earns per pay period.
Frequency of Pay - Indicate how often the employee is paid.
Weekly
Bi-Weekly
Semi-monthly
Monthly
Irregular
Each week
Every other week(i.e. every other Thursday)
Twice per month(i.e. on the 1st and 15th)
Once each month
On an irregular basis
Section 3 – PRE-TAX DEDUCTION INFORMATION
If the employee has pre-tax deductions, provide the amount deducted and how often.
Signature - This form must be completed, signed and dated by the employer or designee. Please provide the title of the person
completing the form. Also, provide a telephone number and fax number if available.
Case : 8136698481
Date : 03/19/2015
Page 06 of 10
STATE OF WISCONSIN
EVFE
EMPLOYER VERIFICATION OF EARNINGS
MUST BE COMPLETED BY THE EMPLOYER (Instructions on the back)
Please return this form by : 2015-03-30
Please return this form to:
CENTRALIZED DOCUMENT PROCESSING UNIT
PO BOX 5234
JANESVILLE WI 535475234
EMPLOYEE INFORMATION
BRIAN SCHOENBECK
EMPLOYER INFORMATION
QPS
FEIN:
Section 1 – EMPLOYMENT STATUS
Is the employee listed above currently employed by your company?
Yes
No
If yes, complete Section 2.
If “no”, Indicate employment end date: ____/____/________
Reason employment ended:
Never employed
Laid Off
Date of final paycheck: ____/____/________
Start date of employment:
Employee Type:
Quit
Strike
Fired
Other
Gross pay for final month: $
Section 2 – EMPLOYMENT INFORMATION
____/____/________
Date first paycheck received: ____/____/________
Temporary
Permanent
Title:
Manager
Other
Please provide an estimate of the following wage information for the next 30 days.
Type of Pay
Best Estimate of
Weekly Hours
Regular:
Overtime:
Other Shift Pay:
Weekend/Shift Differential Pay:
Holiday Pay:
Other:
Salary if not paid hourly:
Bonus and/or Commissions:
Cash and/or Tips:
Frequency of Pay:
Weekly
Rate of Pay
Per Hour
Regular Scheduled
Work Hours
$
$
$
$
$
$
Gross Per Pay Period
$
$
$
Bi-Weekly
Semi-monthly
Monthly
Irregular
Section 3 – PRE-TAX DEDUCTION INFORMATION
Does the employee have any of the following pre-tax deduction?
Type
How much is deducted?
Health insurance premiums:
$
Health care savings accounts:
$
Parking and transit costs:
$
Group life insurance premiums:
$
Retirement contributions:
$
Flexible savings accounts for child care or other dependent care:
$
Employer / Designee Signature:
Print Name:
Title:
How often?
Date: ____/____/________
Phone:__________________
FAX:____________________
Employer Comments
Worker(s):
Moraine Lakes Consortium
Case : 8136698481
Date : 03/19/2015
Page 07 of 10
EMPLOYER VERIFICATION OF EARNINGS INSTRUCTIONS
The Department of Children and Families, the Department of Health Services, a county child support agency or a county
department under s. 46.215, 46.22, or 46.23, a multicounty consortium, a Wisconsin Works (W-2) agency, or a tribal governing
body may request from any person in this state information it determines appropriate and necessary for determining or verifying
eligibility or benefits for a recipient under any income maintenance program, W-2, Child Support enforcement or Wisconsin
Shares. Unless access to the information is prohibited or restricted by law, or unless the person has good cause, as determined by
the departments in accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort
to provide the information within 7 days after receiving a request under this paragraph.
We require employment and wage information concerning the employee named on this Employer Verification of Earning form.
Complete and return the form to the employee as soon as possible so that s/he can return it by the date indicated.
- Review the Federal Employment Identification Number (FEIN) listed on the form. If it is incorrect or missing, write the correct
number on the form, if know.
- This form will be scanned. Write clearly using blue or black ink.
- Write additional comments in the comments section.
Although it is the employee’s responsibility to return this form to the local agency, in order to expedite this process, you may
return this form to the address or fax number if listed. If you do, inform the employee that you have returned this form.
Section 1 – EMPLOYMENT STATUS
If the employee never worked for your company, check the “Never Employed” box. Sign, date and return the form. If the employee
listed on the form is no longer an employee of your company, check the “No” box. Write in the date the employment ended.
Indicate the reason employment ended. Write in the date of the employee’s last paycheck and gross amount (before any
deductions) of pay for his/her final month.
Section 2 – EMPLOYMENT INFORMATION
If the employee listed on the form is employed by your company, check the “Yes” box and complete Section 2. Write in the date
the employee started working for your company and the date of the employee’s first check.
Type of Pay – Provide your best estimate of gross wages (before any deductions) the employee will earn for the next 30 days.
Best Estimate of Weekly Hours – Provide the hours the employee is expected to work weekly.
Rate of Pay Per Hour – If the type of pay is regular, holiday, other shift, overtime, weekend or other type of pay, indicate the
rate of pay the employee earns per hour.
Regularly Scheduled Work Hours – Indicate the employee’s regularly scheduled hours and the days worked (i.e. 8:00 a.m. to
4:30 p.m. Monday, Tuesday, Wednesday and Saturday).
Gross Per Pay Period – If the employee’s type of pay is salary, bonus, commissions, cash and/or tips, write in the gross amount
(before any deductions) the employee earns per pay period.
Frequency of Pay - Indicate how often the employee is paid.
Weekly
Bi-Weekly
Semi-monthly
Monthly
Irregular
Each week
Every other week(i.e. every other Thursday)
Twice per month(i.e. on the 1st and 15th)
Once each month
On an irregular basis
Section 3 – PRE-TAX DEDUCTION INFORMATION
If the employee has pre-tax deductions, provide the amount deducted and how often.
Signature - This form must be completed, signed and dated by the employer or designee. Please provide the title of the person
completing the form. Also, provide a telephone number and fax number if available.
Case : 8136698481
Date : 03/19/2015
Page 08 of 10
5486074654
*** You must include this document as the coversheet for all options ***
Document Tracking Sheet
FROM:
PHONE:
BRIAN SCHOENBECK
_____________________
ATTN:
Moraine Lakes Consortium
Total number of pages: ____
(including this sheet)
Important note: To avoid a delay in processing of your benefits, include this document
tracking sheet and use an option below. Fill in the total number of pages (including this
sheet) and your phone number. Do not write anywhere else on this sheet. Use a separate
sheet of paper if you want to add more information.
Options
Instructions
- If you have a MyACCESS account and a scanner, go to access.wisconsin.gov, log
on to your MyACCESS account and follow the instructions to scan and/or upload
your documents.
- If you do not have a MyACCESS account, you can go to access.wisconsin.gov and
create a new account.
- Use this document tracking sheet as the first page of your fax.
- If your document has information on both sides, copy each side before faxing.
CENTRALIZED DOCUMENT PROCESSING UNIT : (855) 293-1822
- Include this document tracking sheet and mail to:
CENTRALIZED DOCUMENT PROCESSING UNIT
PO BOX 5234
JANESVILLE WI 53547-5234
- Include this document tracking sheet and take to the agency office where you
usually get services or to the following agency:
WASHINGTON COUNTY HSD
333 E. WASHINGTON ST
STE. 3100, P.O. BOX 2003
WEST BEND WI 53095-2502
Confidentiality: This fax should only be used by the person or agency listed above. It may have
information that is private and should not be shared. If you are not the person or agency listed above, it is
against the law to review, use, copy, or share the contents with anyone.
If you get this fax by mistake, please call the sender right away at the phone number above.
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Date : 03/19/2015
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Case : 8136698481
Date : 03/19/2015
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