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Wisconsin WIC Program 
Certification Forms and Publications 

Go directly to FORMS.
Go directly to PUBLICATIONS.

The following forms and publications used by local WIC Projects are available for downloading. They are listed alphabetically by title. 

If you do not find what you want, consult the directory of forms, publications and materials (PDF, 167 KB).  

WIC Forms
Title Number Format
Affirmation of Identity, Residency and/or Income in English  
(10/06)  		F-40019 PDF, 15 KB 
Affirmation of Identity, Residency and/or Income in Hmong   F-40019H Stored in the ROSIE system.
Affirmation of Identity, Residency and/or Income in Spanish  
(11/06)		 F-40019S PDF, 15 KB 
Civil Rights Discrimination Complaint Form 
in English  
(06/11) 		F-40082 PDF, 45 KB 
Civil Rights Discrimination Complaint Form 
in Hmong  		F-40082H Stored in the ROSIE system.
Civil Rights Discrimination Complaint Form  
in Spanish 
(06/11) 		F-40082S PDF, 12 KB 
Complaint Form for WIC Vendors and Participants  
(02/01)  		F-44322 PDF, 14 KB
Confidential Information Release Authorization in English 
(07/08)  		F-82009 ii PDF, 15 KB
Confidential Information Release Authorization in Hmong 
(07/08)  		F-82009 ii H PDF, 25 KB
Confidential Information Release Authorization in Spanish 
(07/08)  		F-82009 ii S PDF, 9 KB
Disqualification Notice   F-40080
F-40080H
F-40080S		 Stored in the ROSIE system.
Hearing Request Form   F-40083
F-40083H
F-40083S		 Stored in the ROSIE system.
Ineligibility Notice in English  
(05/06) 		F-40085 PDF, 30 KB
Ineligibility Notice in Hmong   F-40085H Stored in the ROSIE system.
Ineligibility Notice in Spanish
(05/06)  		F-40085S PDF, 41 KB
Lost or Stolen Check Replacement Agreement
(07/06)  		F-40094 PDF, 29 KB
Lost or Stolen Check Replacement Agreement
(07/06)		 F-40094 Word-fillable
Repayment Agreement  
(07/06)  		 F-40096 PDF, 25 KB
Repayment Agreement with Proxy Designation  
(07/06)   		 F-40095 PDF, 25 KB
Rights and Responsibilities  
in English
(05/11)  		F-44161 PDF, 17 KB
Rights and Responsibilities  
in Hmong 
(05/11)  		F-44161H PDF, 36 KB 
Rights and Responsibilities  
in Spanish 
(05/11) 		 F-44161S PDF, 32 KB
Waiting List Notice  F-40084
F-40084H
F-40084S		 Stored in the ROSIE system.
Warning Letter  F-40081
F-40081H
F-40081S		 Stored in the ROSIE system.
WIC Identification Folder Insert
in Hmong
(01/10)  		None PDF, 16 KB
WIC Prescriptions/Clinical Data
for children 
(09/10)  		F-44024B PDF, 25 KB
WIC Prescriptions/Clinical Data
for infants 
(08/10)  		F-44024D PDF, 27 KB
WIC Prescriptions/Clinical Data
 for women 
(09/10)  		F-44024A PDF, 24 KB

WIC Publications
Title Number Format
Approved Foods Booklet
in English, Hmong and Spanish
(11/10)  		P-44578
P-44578H
P-44578S		 PDF
Approved Breads and Tortillas Card
in English, Hmong and Spanish
(03/11) 		 P-00186
P-00186H
P-00186S		 PDF
Formula and Medical Food:
Child Formulas, Medical Foods and Other Foods, Prescription Required 
(08/11)    		P-40077C PDF, 61.83 KB
Formula and Medical Food:
Infant Formulas, Contract Standard 
(08/11)    		P-40077A PDF, 39.64 KB
Formula and Medical Food:
Infant Formulas, Exempt, Prescription Required 
(08/11)    		P-40077B PDF, 79.64 KB
Formula and Medical Food:
Women's Medical Foods and Other Foods, Prescription Required 
(08/10)   		P-40077D PDF, 31 KB

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Last Revised:  September 20, 2011