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Women Infants & Children (WIC) Application

  1. Women Infants and Children (WIC) Application
  2. This is my*
  3. Text Appointment Reminder Okay?
  4. This is my
  5. 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.

  6. upload your proof of household address document here

  7. You, the Applicant are the:*
  8. Gender*
  9. Primary Language*
  10. Do you need an interpreter?
  11. Have you been on WIC before?*
  12. Eligibility Requirements
  13. Are you or any member of your family on MA or MN Care?*
  14. Are you or any of your family members on any of the following programs? *
  15. 1st Person's Income
  16. Overtime?*
  17. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*
  18. Is there a second wage earner in your household? *
  19. 2nd Person's Income
  20. Overtime?
  21. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?
  22. 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.

  23. upload your proof of household income documents here

  24. upload any additional proof of household income documents here

  25. upload any additional proof of household income documents here

  26. Women
  27. Are you pregnant?*
  28. Are you breastfeeding?*
  29. Are you using formula?*
  30. Are there children under 5 in your household?*
  31. Gender
  32. Gender
  33. Gender
  34. Gender
  35. Gender
  36. 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.

  37. upload proof of identity document here

  38. upload any additional proof of identity documents here

  39. upload any additional proof of identity documents here

  40. 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:

  41. 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.

  42. Leave This Blank:

  43. This field is not part of the form submission.