Free WIC Repayment Agreement with Proxy, DPH 40095 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40095 (07/06)

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

WIC PROGRAM REPAYMENT AGREEMENT WITH PROXY DESIGNATION I, , agree to repay $______________ to the WIC Program for benefits fraudulently received. I will make payments as scheduled below. Failure to make the payments as scheduled may result in all family members being disqualified from the WIC Program until full repayment is made. I understand that I must not pick up or spend WIC checks until full repayment is made. I have chosen a proxy to pick up and spend WIC checks. I am responsible if the proxy does not use the checks properly. Date $ $ $ $ $ $ $ $ $ $ $ Amount $ $ $ $ $ $ $ $ $ $ $ Balance

SIGNATURE ­ WIC Participant/Parent/Guardian/Foster Parent/Caregiver

Date Signed

SIGNATURE ­ Local Project Director or Designee

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.