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2. Name:
3. Daytime phone number:
5. Address:
6. Apt/Lot
8. City:
9. Zip Code:
11. Total Number of people in the Household:
    (including children over age 5, parents/sibling, significant others/spouses)
13. Please list the names and birthdates of the pregnant, breastfeeding, or newly postpartum mother and all children under age 5:
    Names and Date of Births
15. INCOME: Please check all that apply

    1. Medical Assistance
    2. Enrolled in Headstart or on waitlist
    3. Receiving Energy Assistance
    4. MNCare
    5. MFIP/Financial Assistance
    6. Receiving Supplemental Security Income
    7. Free or Reduced School Lunch
    8. SNAP/Food Stamps
17. Include all earnings (before tax income) in the household, including social security benefits and child support payments.
19. Annual Total Income
20. or Monthly total Income
21. or Bi-Weekly total Income
23. or Hourly rate
24. Hours per Week
26. Have you been on WIC before?

    1. Yes
    2. No
27. If you have been on WIC before, previous last name
29. This institution is an equal opportunity provider
31. View the Non-Disclosure Agreement
    Non-Disclosure Agreement
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field