Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40019 (Rev 10/06)

STATE OF WISCONSIN

AFFIRMATION OF IDENTITY, RESIDENCY, AND/OR INCOME
Participation in WIC is voluntary. Personally identifiable information is used to determine WIC eligibility and may be disclosed to others only as allowed by state and federal laws.

Date: __________________________ Guardian: Participant Name: Participant Name: Participant Name: Family ID: Participant ID: Participant ID: Participant ID:

I understand that I must provide WIC with written documentation as proof of the total household income, my identity and residency to determine my eligibility for WIC benefits. I cannot provide proof of my total household income because:

I affirm that the total gross income (Such as wages, child support, social security income, tips, workman's compensation, unemployment, etc.) is $ weekly/every two weeks/twice a month/ monthly. (Circle how often you receive income)

I cannot provide proof of my residency because:

I affirm that my address is:

I cannot provide proof of my identity because:

By signing this form, I am certifying that the information I have provided is correct to the best of my knowledge. I understand that intentionally making a false statement or intentionally misrepresenting, concealing, or withholding facts may result in termination from the program; paying the state agency, in cash, the value of the food benefits improperly issued to me; and may subject me to civil or criminal prosecution under state and federal law.

(Applicant/Participant/Guardian's Signature and Date)

(WIC Staff Signature and Date)

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.