Free None - Wisconsin

Department of Health Services Division of Public Health F-44621 (Rev. 02/09)

WIC STOCK PRICE SURVEY

STATE OF WISCONSIN Wis. Admin. Code § 149.08(3)(d), 149.11(2)(f) (608) 266-6912

Store Name Street Address City, State, ZIP

WIC Stamp Number

INSTRUCTIONS: Please refer to the WIC Approved Food List for authorized items. Submit the highest shelf price for WIC approved items available in the customer area of the store. Prices are required for six cereals and the items that are highlighted in gray and marked with a $ in the price box. If your survey does not indicate that your store meets the minimum stock requirements (see page 3), the stock price survey will be returned as incomplete. A completed form is required for WIC vendor authorization and when requested. Failure to complete this form may result in denial of your application or vendor disqualification. CEREAL- WIC approved brands only. Provide prices for the six most expensive cereals (determined by price per ounce) Brand (for example- Kellogg's) Product Name (for example- Cheerios, Kix) Size (oz) Price $ $ $ $ $ $ CHEESE ­ any approved type, blocks only except American slices, no specialty or deli List price for 1 lb (16 oz.) (required) $

MILK- any brand /type white milk in plastic containers or cartons; no organic or flavored milk Gallon (required) Half-gallon (64 oz) Evaporated- 12 oz can LACTOSE FREE MILK- any brand including calcium fortified Quart (32 oz) Half-gallon (64 oz) EGGS- any size; no organic, natural, or other modified or specialty eggs One- dozen carton (required) $ $

DRIED BEANS/PEAS- any brand/type; no seasoned, added ham bits, organic 1 lb (16 oz) bag (required) $

100% JUICE - any approved brand/type; no juice cocktails, beverages, or organic juices 11.5 - 12 oz. frozen concentrate (LEAST $ required) 46 oz. can or plastic bottle (required) 64 oz. refrigerated carton (calcium added only) 6 pk. 5.5 - 6 oz. cans PEANUT BUTTER - any brand/type; no refrigerated, organic, dietetic or health food product, or individual servings 18 oz. jar (required) $ INFANT CEREAL ­ Gerber brand only; any grain; no added DHA, fruit, formula, yogurt 8 oz. box (required) $ $ $

F-4 4621 (Rev. 02/09)

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TUNA - canned chunk light tuna only; no pouches, albacore, white or fillets 5 oz. can CARROTS - whole fresh, baby, frozen or canned; no organic, sliced or cut fresh 1 lb (16 oz) package

INFANT FORMULAS AND LIQUID NUTRITION PRODUCTS
Instructions: Print the prices for infant formula and liquid nutrition products that are on the shelf in the customer area or may be ordered upon request.

Nestle® Good Start® Supreme DHA & ARA - Powder Concentrated Liquid (required if no price for powder above) Ready-To-Feed Good Start® Supreme Soy DHA & ARA - Powder Concentrated Liquid Ready-To-Feed Good Start® Supreme - Powder Good Start® Natural Cultures - Powder Boost - Ready-To-Feed (any kind) Ross Products Div., Abbott Laboratories Elecare - Powder Ensure - Ready-To-Feed (any kind) Ready-To-Feed (any kind) PediaSure - Ready-To-Feed (any kind except Enteral) Similac Alimentum DHA & ARA - Powder Ready-To-Feed Similac Neosure DHA & ARA - Powder Ready-To-Feed Mead Johnson Nutritionals Enfamil AR LIPIL - Powder Ready-To-Feed Enfamil Enfacare LIPIL - Powder Ready-To-Feed Nutramigen LIPIL - Powder Concentrated Liquid Ready-To-Feed Pregestimil LIPIL - Powder Nutricia North America Neocate Infant DHA & ARA - Powder

UPC Code 050000216673 050000216697 050000216703 050000035304 050000034574 050000034598 050000120215 050000625505 041679xxxxxx 070074xxxxxx 070074xxxxxx 070074xxxxxx 070074xxxxxx 070074576640 070074575131 070074574318 070074574561 300870201423 300870203731 300870019448 300871287419 300870338013 300870498014 300870499011 300870367013 749735025956

Size 12 oz. 13 oz. 1 qt. (32 oz.) 12.9 oz. 13 oz. 1 qt. (32 oz.) 12 oz. 12 oz. 8 oz. 14.1 oz. 8 oz. 1 qt. (32 oz.) 8 oz. 1 Ib. 1 qt. (32 oz.) 12.8 oz. 1 qt. (32 oz.) 12.9 oz. 1 qt. (32 oz.) 12.8 oz. 1 qt. (32 oz.) 1 Ib. 13 oz. 1 qt. (32 oz.) 1 Ib. 14 oz.

Price $

/6 pack

/6 pack /6 pack

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F-44621 (Rev. 02/09)

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Minimum stock requirements are as follows: Milk - 20 gallons unflavored milk Eggs - 8 one-dozen cartons Cheese - 4 pounds, two blocks each of different types Cereal - 4 boxes each of six different types of cereal Juice - 28 containers (combination of frozen concentrate and 46 oz. containers) Dried Beans/Peas - 4 lbs., 2 one-pound bags of two different types Peanut Butter - 4 containers 18 oz. Infant Cereal - 6 boxes 8 oz., Gerber brand only, two types
AFFIDAVIT I hereby indicate that the above prices represent the NORMAL, non-sale price of merchandise as of this date and that the minimum stock requirements for WIC vendor authorization are maintained at all times. Store Name WIC Stamp Number

Prepared By (print)

Title

Name- Owner, store manager or other Individual who has authorization to sign on behalf of the vendor (print) Signature- Owner, store manager or other individual who has authorization to sign on behalf of the vendor

Title

Date

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F-44621 (Rev. 02/09)

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