W-2 Good Cause Notice
Personal information you provide may be used for secondary purposes [Privacy Law, S. 15.04(1)(m), Wisconsin Statutes].
To receive Wisconsin Works (W-2) services, Child Care Assistance (CC), Caretaker Supplement (CTS), BadgerCare Plus (BC+) or Medicaid, you are required by law to cooperate with the W-2, county or tribal human/social services and child support agencies. You must cooperate in getting any support (financial or medical) owed to you and any child for whom you want W-2, CC, CTS, BC+ or Medicaid. Any parent in a W-2 household must cooperate to receive W-2 or CC services. The eligibility of children and pregnant women for Medicaid is not affected if you fail to cooperate.
Cooperation means that you may have to do one or more of the following:
Your cooperation is important because it may help you and your child(ren):
You may have a good reason for not cooperating. The following are circumstances under which the Wisconsin Works (W-2), county or tribal human/social services agency may find that you have "good cause" for not cooperating:
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.
If your claim of "good cause" for not cooperating with the Child Support agency is denied by the W-2, county or tribal human/social services agency, you will not be eligible for W-2 services, CC, CTS, BC+ or Medicaid unless you begin to cooperate. If you are receiving BC+ or Medicaid your child(ren) may still be eligible. The W-2, county or tribal human/social services and Child Support agencies will continue in the effort to obtain any financial and medical support for the child(ren) who are covered by Medicaid.
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 writing your worker or W-2 agency within 45 days of the decision date.
If you are receiving BC+, Medicaid, CTS, or CC, 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 and understand this notice explaining my right to claim "good cause" for declining to cooperate.
Re: 42 CFR 433.147 and Wis Stats. 49.151, 49.155(1m)(b), 49.124 and 49.775
DCF-F-DWSP2018 (R. 05/2019)
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Document Name: W-2 Good Cause Notice
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