WIC Forms and
Publications
The following forms and publications used by local WIC projects are
available for downloading. If you don't find what you want, try the complete
list of DPH forms and the directory of WIC
publications (PDF, 167 KB).
CERTIFICATION
| Title |
Number |
Format |
| Affirmation
of Identity, Residency and/or Income in English (10/06) |
DPH
40019 |
PDF,
15 KB
|
| Affirmation
of Identity, Residency and/or Income in Spanish (11/06) |
DPH
40019S |
PDF,
15 KB
|
Approved
Foods Brochure (11/07)
(Very large file; may download slowly) |
PPH
4578 |
PDF,
7 MB
|
| Approved
Foods List in English (11/07) |
PPH 4728 |
PDF,
19 KB |
| Approved
Foods List in Spanish (11/07) |
PPH 4728S |
PDF, 22 KB |
Civil Rights
Discrimination Complaint Form
in English (08/06)
|
DPH
40082 |
PDF,
15 KB |
Civil Rights
Discrimination Complaint Form
in Spanish (09/06)
|
DPH
40082S |
PDF,
15 KB |
| Complaint
Form for WIC Vendors and Participants (02/01)
|
DPH
4322 |
PDF,
14 KB |
| Confidential
Information Release Authorization in English (05/03)
|
HFS
9 II |
PDF,
15 KB |
| Confidential
Information Release Authorization in Hmong (05/03)
|
HFS
9 II H |
PDF,
25 KB |
| Confidential
Information Release Authorization in Spanish (05/03)
|
HFS
9 II S |
PDF,
9 KB |
| Disqualification
Notice is found in the "Letters" section of the ROSIE
system.
|
DPH
40080
DPH 40080S |
N/A |
| Hearing
Request Form is found in the "Letters" section of the
ROSIE system. |
DPH
40083
DPH 40083S |
N/A |
| Income
Guidelines (12/05) |
PPH
4501 |
PDF,
72 KB
|
| Ineligibility
Notice in English (05/06)
|
DPH
40085 |
PDF,
30 KB |
| Ineligibility
Notice in Spanish (05/06)
|
DPH
40085S |
PDF,
41 KB |
| Lost or
Stolen Check Replacement Agreement (07/06) (Word-fillable
version)
|
DPH
40094 |
PDF,
29 KB |
| Repayment
Agreement (07/06) |
DPH
40096 |
PDF,
25 KB |
| Repayment
Agreement with Proxy Designation (07/06) |
DPH
40095 |
PDF,
25 KB |
| Rights and Responsibilities
in English (05/08) |
DPH 4161 |
PDF, 17 KB |
Rights and Responsibilities
in Hmong
(05/06)
|
DPH
4161H |
PDF,
36 KB |
| Rights and Responsibilities
in Spanish (03/06) |
DPH 4161S |
PDF,
32 KB |
|
WIC Formula and Medical Nutritional Prescriptions / Clinical Data --
Infants and Children (04/08)
|
DPH 4024B |
PDF, 21 KB |
WIC
Medical Nutritional Prescriptions/
Clinical Data -- Pregnant,
Breastfeeding and Non-Breastfeeding Postpartum Women (06/06) |
DPH 4024A |
PDF, 21 KB |
| Wisconsin
WIC Approved Formulas and Medical Foods (04/08)
|
PPH
40077 |
PDF,
46 KB |
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