Free WIC Lost or Stolen Check Replacement Agreement, DPH 40094 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40094 (07/06)

STATE OF WISCONSIN Bureau of Community Health Promotion Fed. Reg. 7 CFR 246

WIC PROGRAM LOST OR STOLEN CHECK REPLACEMENT AGREEMENT
Name(s) of participant(s) issued checks that were reported lost or stolen: Family ID Number:

Provide details of how WIC checks were lost or stolen. Include place, dates, police reports, etc. if available.

Participant's WIC checks for __________________to___________________ (enter first-date-to-use and last-date-to-use) have been replaced. Listed below are the first-date-to-use and the check numbers for all original and replacement checks. FIRST-DATETO-USE ORIGINAL CHECK NUMBER FIRST-DATETO-USE REPLACEMENT CHECK NUMBER

I certify that the WIC checks reported above were lost or stolen from me. If the checks are found, I will return them to the WIC office. If these checks are used by myself or my proxy, I understand that I will have to pay money back to the WIC Program for food I should not have received.
WIC Participant/Parent/Proxy (please print)

SIGNATURE ­ WIC Participant/Parent/Proxy

Date Signed

SIGNATURE ­ Local WIC Agency Representative

Date Signed

WIC Project Name

WIC Project Number

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the 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.