To submit the form, please send it to the following address: [Insert Physical Address Here]. Alternatively, you can submit it via email to [Insert Email Address Here] or fax it to [Insert Fax Number Here]. Make sure all sections are fully completed and signed before submission. Advice: Double-check all information and required documents before submission to avoid any delays in processing your application.

Important dates for this form may include the application start and end periods in 2024 and 2025. Additionally, certification and follow-up appointment dates should be noted.

The purpose of this form is to gather detailed information about applicants for WIC benefits, ensuring the accurate assessment of eligibility. It captures essential details about the infant, parent or guardian, and household demographics. By using this form, WIC program staff can verify the applicant's identity, residence, income, and health information to determine the appropriate support.

• 1. eWIC card #: Unique identifier for the WIC benefits card.
• 2. Application Date: The date the application was filled out.
• 3. Client Present: Whether the client was present at the time of application.
• 4. Not Present Justification: Reason for the client's absence, if applicable.
• 5. Applicant: Details about the applicant including identification and demographics.
• 6. Continuity of Services Form: Form used to ensure continued services and benefits.
• 7. Name: Full name of the infant.
• 8. DOB: Date of birth of the infant.
• 9. Sex: Gender of the infant.
• 10. Proof of identification: Verification documents for the infant's identity.
• 11. Ethnicity: The infant's ethnic background.
• 12. Race: The infant's race as identified.
• 13. Address: Physical address of the applicant.
• 14. Proof of residence: Documentation confirming the applicant's residence.
• 15. Foster care: Indicates if the infant is in foster care.
• 16. Homeless: Indicates if the applicant is homeless.
• 17. Migrant: Indicates if the applicant is a migrant.
• 18. Adjunct program participation: Participation in other assistance programs like ISNAP, Medicaid.
• 19. Certification: Confirmation of certification eligibility.
• 20. Mid-Certification Assessment: Evaluation done mid-way through the certification period.
• 21. Parent/Guardian: Details of the parent or guardian including identification and relationship to the infant.
• 22. Caretaker: Information about the caretaker, if different from the parent or guardian.
• 23. Telephone #: Contact number of the applicant.
• 24. Preferred method of contact: The best way to reach the applicant, e.g. Home, Work, Cellular.
• 25. Language: Spoken and read language preferences.
• 26. Voter Registration: Indicates whether the voter registration form was provided or declined.
• 27. Family Assessment: Assessment of the family including smoking habits and size.
• 28. Income: Details about income sources and verification documents.
• 29. Zero-Income Declaration: Declaration of no income for eligibility assessment.
• 30. Certification Signature: Signature for certifying the information provided.
• 31. Applicant/Parent/Guardian/Caretaker Signature: Signature of the applicant, parent, guardian, or caretaker.
• 32. Anthro/Lab: Anthropometric and laboratory data section.
• 33. Health Information: Medical conditions, birth details, and health status.
• 34. Medical Conditions: Specific medical conditions affecting the infant.
• 35. Medications and Supplements: Medications and supplements the infant is taking.
• 36. Immunizations: Immunization status of the infant.
• 37. Feeding complications: Any complications related to infant feeding.
• 38. Nutrition Education: Nutrition education details and risk criteria.
• 39. Referrals: Referrals to healthcare or social support services.
• 40. Goals: Goals set for the infant's nutrition and health.
• 41. Care Plan: A detailed care plan for the infant.
• 42. Food Prescription: Prescribed food packages for the infant.
• 43. Follow-up / Next Appointment: Details of the follow-up or next appointment.
• 44. Certifier/CPA: Signature and title of the certifying authority.
• 45. AFFIDAVIT FOR PROOF OF IDENTITY, RESIDENCY, and/or INCOME: Affidavit for cases where proof is difficult or harmful to obtain.
• 46. Staff Signature: Signature of the staff member verifying the form.

Failure to submit this form can result in a delay or denial of WIC benefits. Completing and submitting the form accurately is crucial for receiving assistance.

• Delay in Benefits: Your application may be delayed, causing a gap in receiving necessary support.
• Denial of Eligibility: Failure to provide required information might lead to a denial of benefits.
• Incomplete Documentation: Missing or inaccurate information can result in incomplete documentation and affect your eligibility.

• 1. WIC Application: When applying for WIC benefits for infants.
• 2. Income Verification: When you need to verify and document your income for eligibility.
• 3. Health Information Documentation: When recording health and medical details for the infant.
• 4. Demographics Information: When providing demographic details to support the application.
• 5. Zero-Income Declaration: When declaring zero income for eligibility assessment.