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2. Women Infants and Children (WIC) Application
4. First Name*
5. Middle Initial*
6. Last Name*
8. Birthdate*
   Birthdate
10. Address*
12. City*
13. State*
14. Zip Code*
16. Phone*
17. This is my*

    1. Home
    2. Work
    3. Mobile
18. Text Appointment Reminder Okay?

    1. Yes
    2. No
20. Alternative Phone
21. This is my

    1. Home
    2. Work
    3. Mobile
23. Email*
25. Proof of Household Address*

    You will need to provide proof of a Minnesota home address. you can provide proof of your address now or at your appointment. 

    Anyone of the following can be used as long as the address is shown: 
    - Bill
    - Driver's License
    - Lease or Rental Agreement
    - Mail Addressed to You
    - Pay Stub
    - Rent Receipt
    - State ID
    - Statement from Employer
    - Statement from Landlord
    - WIC Appointment Letter

    Do you want to upload a proof of your household address now (e.g. photo, PDF)?
    Uploading documents is optional but loading them now may save time during your appointment.

    1. Yes
    2. No
27. Proof of household address documents

    upload your proof of household address document here

31. You, the Applicant are the:*

    1. Mother
    2. Father
    3. Foster Parent / Guardian / Other
32. Gender*

    1. Male
    2. Female
34. Primary Language*

    1. English
    2. Spanish
    3. Somali
    4. Other
35. Do you need an interpreter?

    1. Yes
    2. No
37. Have you been on WIC before?*

    1. Yes
    2. No
39. Where were you previously on WIC?
43. Eligibility Requirements
45. Current number in household (include unborn baby) *
46. Are you or any member of your family on MA or MN Care?*

    1. Yes
    2. No
48. Are you or any of your family members on any of the following programs? *

    1. SNAP
    2. Free / Reduced School Lunch
    3. Fuel Assistance
    4. Head Start
    5. MFIP
    6. SSI or TEFRA (only the person receiving these benefits would be eligible for the WIC program)
    7. None of the above
52. 1st Person's Income
54. Hourly Wage*
55. Hours per Week*
56. Overtime?*

    1. Yes
    2. No
57. Average overtime hours per week:
59. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*

    1. Yes
    2. No
61. Source
62. Amount
63. Source
64. Amount
66. Other Income
68. Is there a second wage earner in your household? *

    1. Yes
    2. No
72. 2nd Person's Income
74. Hourly Wage
75. Hours per Week
76. Overtime?

    1. Yes
    2. No
77. Average overtime hours per week:
79. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*

    1. Yes
    2. No
81. Source
82. Amount
83. Source
84. Amount
86. Other Income
90. Proof of your household income

    You will need to provide proof of your household income. You can provide proof of your income now or at your appointment. 

    Provide all household income. Any of the following can be used:
    - Child Support payments/letter
    - Pay Stub
    - Payment Award Letter
    - Pension or Annuity
    - Statement from Employer
    - Tax Form
    - Unemployment Documents
    - Veteran's Payment
    - W-2 Form
    - Alimony
    - Military Pay Documentation
    - Migrant - Income Exception
    - Social Security/SSI

    Do you want to upload documents for proof of your household income (e.g. photo, PDF)?
    Uploading documents is optional but loading them now may save time during your appointment.

    1. Yes
    2. No
92. Proof of household income documents

    upload your proof of household income documents here

94. Additional proof of household income documents

    upload any additional proof of household income documents here

96. Additional proof of household income documents

    upload any additional proof of household income documents here
    
    

100. Women
102. First Name*
103. Middle Initial*
104. Last Name*
106. Birthdate*
     Birthdate
107. Are you pregnant?*

     1. Yes
     2. No
108. My due date is:
     My due date is:
110. Are you breastfeeding?*

     1. Yes
     2. No
111. Are you using formula?*

     1. Yes
     2. No
112. What brand of formula are you using?
116. Are there children under 5 in your household?*

     1. Yes
     2. No
117. Number of children under 5 in your household:
119. 1st Dependent's Name
120. Middle Initial
121. Last Name
123. Birthdate
     Birthdate
124. Gender

     1. Male
     2. Female
126. 2nd Dependent's Name
127. Middle Initial
128. Last Name
130. Birthdate
     Birthdate
131. Gender

     1. Male
     2. Female
133. 3rd Dependent's First Name
134. Middle
135. Last Name
137. Birthdate
     Birthdate
138. Gender

     1. Male
     2. Female
140. 4th Dependent's First Name
141. Middle
142. Last Name
144. Birthdate
     Birthdate
145. Gender

     1. Male
     2. Female
147. 5th Dependent's First Name
148. Middle
149. Last Name
151. Birthdate
     Birthdate
152. Gender

     1. Male
     2. Female
156. Proof of Identity

     You will need to provide proof of identity. You can provide proof of identity now or at your appointment.
     
     Any one of the following can be used:
     - Birth Certificate
     - Checkbook
     - Driver's License
     - Health Benefits Card
     - Hospital Discharge Paper
     - Immigration Record
     - Medical Record
     - Naturalization Record
     - Official Government/State ID
     - Passport/Visa
     - Pay Stub
     - Photo ID
     - School ID
     - Social Security Card
     - Voter Registration Card

     Do you want to upload a proof of identity (e.g. photo, PDF)?
     Uploading documents is optional but loading them now may save time during your appointment.

     1. Yes
     2. No
158. Proof of Identity Documents

     upload proof of identity document here
     
     

160. Additional Proof of Identity Documents

     upload any additional proof of identity documents here
     
     

162. Additional Proof of Identity Documents

     upload any additional proof of identity documents here
     
     

166. Additional Information you would like us to consider .
168. Link to WIC Non-Discrimination Statement
     https://www.health.state.mn.us/people/wic/nondiscrim.html
170. Public Health Nurse Outreach*

     Our Benton County Public Health Nursing Program can provide information on healthy pregnancies, giving birth, breastfeeding, parenting and other helpful resources. If you are interested, by selecting 'Yes' below, you are giving the Benton County WIC Program your permission to release and exchange the following information with the nurses from the Benton County Public Health Nursing Program: 
     - Information collected about me or my child as follows: name, date of birth, address and telephone number. 
     - Information about whether I participate in the WIC program. 

     The Benton County Public Health Nurses will use the information to provide services under those programs if I am eligible and wish to participate. I understand that I do not have to agree to the release of information described in this document. I also understand refusing to sign this authorization will not affect my participation in the WIC Program, will not affect the current or future care I receive from any health care provider, and will not cause any penalty or loss of benefits to which I am otherwise entitled. I may cancel my permission at any time in writing. I understand the written cancelation will not affect information the agency has already released, requested, or received. This authorization will expire one year from today. 

     I wish to release my information to the Benton County Public Health Nursing Program:

     1. Yes
     2. No
172. Public Health Nurse Outreach Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
174. Electronic Signature
Leave This Blank:


176. 1. Receive an email copy of this form.
177. Email address

     This field is not part of the form submission.

178. Submit Submit and Print

* indicates a required field