Free WIC Income Statement, DPH 40076 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40076 (Revised 01/05)

STATE OF WISCONSIN

WOMEN, INFANTS, AND CHILDREN (WIC) NUTRITION PROGRAM INCOME STATEMENT Employee: Completion of this form is voluntary. It will be used only by the WIC Program for proof of income for employees who do not receive a paycheck stub. Proof of income is needed for enrollment in the WIC Program. Employer: Please complete the following and return the original form to the employee. Employee Name________________________________________________________ Gross Income (The most current income is needed) ____________________________ Date this income was provided: ____________________________________________

________________ hourly wage

________________ weekly income

______________ hours per week

OR

Employer: Name of Business______________________________________________ Address_______________________________________________________________ Telephone_____________________________________________________________

By signing my name, I acknowledge that the information I have given is correct, to the best of my knowledge.

Employer Printed Name _________________________________________________

Employer Signature __________________________Date Signed________________

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.