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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 up to age 5:
15. First Name
16. Last Name
17. Date of Birth
19. First Name
20. Last Name
21. Date of Birth
23. First Name
24. Last Name
25. Date of Birth
27. First Name
28. Last Name
29. Date of Birth
31. First Name
32. Last Name
33. Date of Birth
35. 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
37. Include all earnings (before tax income) in the household, including social security benefits and child support payments.
39. Annual Total Income
40. or Monthly total Income
41. or Bi-Weekly total Income
43. or Hourly rate
44. Hours per Week
46. Have you been on WIC before?*

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


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field