The following forms and publications used by local WIC Projects are
available for downloading. They are listed alphabetically by title.
|
WIC Forms |
| Title |
Number |
Format |
| Affirmation
of Identity, Residency and/or Income in English
|
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
|
F-40019S |
PDF,
15 KB
|
Civil Rights
Discrimination Complaint Form
in English |
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
|
F-40082S |
PDF,
12 KB |
| Complaint
Form for WIC Vendors and Participants
|
F-44322 |
PDF,
14 KB |
| Confidential
Information Release Authorization in English
|
F-82009
ii |
PDF,
15 KB |
| Confidential
Information Release Authorization in Hmong
|
F-82009
ii H |
PDF,
25 KB |
| Confidential
Information Release Authorization in Spanish
|
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
|
F-40085 |
PDF,
30 KB |
| Ineligibility
Notice in Hmong
|
F-40085H |
Stored in
the
ROSIE system. |
| Ineligibility
Notice in Spanish |
F-40085S |
PDF,
41 KB |
|
Lost or
Stolen Check Replacement Agreement in English
|
F-40094 |
Word-fillable |
|
Lost or
Stolen Check Replacement Agreement in English
|
F-40094 |
PDF, 19 KB |
|
Lost or
Stolen Check Replacement Agreement in
Hmong
|
F-40094H |
Word-fillable |
|
Lost or
Stolen Check Replacement Agreement in
Hmong |
F-40094H |
PDF, 19 KB |
|
Lost or
Stolen Check Replacement Agreement in
Spanish |
F-40094S |
Word-fillable |
|
Lost or
Stolen Check Replacement Agreement in
Spanish |
F-40094S |
PDF, 19 KB |
|
Repayment
Agreement in English |
F-40096 |
PDF,
25 KB |
|
Repayment
Agreement in Hmong
|
F-40096H |
PDF,
25 KB |
|
Repayment
Agreement in Spanish
|
F-40096S |
PDF,
25 KB |
|
Repayment
Agreement with Proxy Designation in English |
F-40095 |
PDF,
25 KB |
|
Repayment
Agreement with Proxy Designation in
Hmong |
F-40095H |
PDF,
25 KB |
|
Repayment
Agreement with Proxy Designation in
Spanish |
F-40095S |
PDF,
25 KB |
| Rights and Responsibilities
in English
|
F-44161 |
PDF, 17 KB |
| Rights and Responsibilities
in Hmong |
F-44161H |
PDF,
36 KB |
| Rights and Responsibilities
in Spanish |
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 |
None |
PDF,
16 KB |
| WIC
Prescriptions/Clinical Data
for children |
F-44024B |
PDF,
25 KB |
| WIC
Prescriptions/Clinical Data for infants
|
F-44024D |
PDF,
27 KB |
| WIC
Prescriptions/Clinical Data
for women |
F-44024A |
PDF,
24 KB |
|
WIC Publications |
| Title |
Number |
Format |
Approved
Foods Booklet
in English, Hmong and Spanish
|
P-44578
P-44578H
P-44578S |
PDF
|
Approved
Breads and Tortillas Card
in English, Hmong and Spanish |
P-00186
P-00186H
P-00186S |
PDF
|
Formula
and Medical Food:
Child Formulas, Medical Foods and Other Foods, Prescription
Required
|
P-40077C |
PDF,
61.83 KB |
Formula
and Medical Food:
Infant Formulas, Contract Standard
|
P-40077A |
PDF,
39.64 KB |
Formula
and Medical Food:
Infant Formulas, Exempt, Prescription Required |
P-40077B |
PDF,
79.64 KB |
Formula
and Medical Food:
Women's Medical Foods and Other Foods, Prescription Required
|
P-40077D |
PDF,
31 KB |
