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WIC Application

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