Forms

Extra Vendor Stamp Order Form
Form used by WIC retailers when there is a need to order new WIC Vendor stamp(s).  When completed, the retailer returns the form and payment to the address indicated on the form. 

Retailer Order Form – WIC-5a
Form used by WIC retailers to request WIC retailer supplies.  When completed, the retailer returns the form to the state WIC office for processing.

Partial WIC Formula Redemption Form – WIC-21
Form used by WIC retailers when they do not have enough formula in their stock to meet the demands on a WIC Check. When completed by the retailer and returned to the agency by the participant, the participant can be given an additional food instrument to make up the difference of what was not available before.

Retailer Training Form – WIC-22
Form used by WIC retailers to document employee training regarding WIC transactions.

Retailer Concern Form – WIC-76
Form used by WIC retailers and returned to the state WIC office to report specific problems, concerns or suggestions that retailers may have with WIC transactions, including WIC customers, WIC checks and local WIC providers.

Approval Request For Non-Paid Checks Form – WIC-77
Form used by WIC retailers when a WIC check has been denied for payment.  When completed by the retailer, the form is sent to the state WIC office along with the WIC check and matching register receipt.