Virginia WIC Program
SUPPLEMENTAL INFORMATION FORM
1. Store Trade Name: WIC ID:
☐ Corporate Store ☐ Independent Store ☐Other (Explain):
2. Owner or Corporation Name: Fed Tax ID:
3. Owner/Corp Contact phone: ( ) Owner/Corp Contact email:
4. Store Mailing Address:
5. City, State, ZIP: Store Phone: ()
6. Store Contact Name: Store Contact phone: ()
7. Store Contact email: Store Contact mobile: ( )
8. Grocery Supplier Name:
9. Formula Supplier/Distributor Name:
10. Formula Supplier/Distributor Address:
11. City, State, ZIP: Phone: ()
12. Sales:
Annual Gross Total Food Sales: $ For year: ☐Actual ☐Projected (check one)
Annual Gross Non Food Sales: $ For year: ☐Actual ☐Projected (check one)
13. Do Registers scan product bar codes/UPCs? ☐ Yes ☐ No
14. Do Registers electronically identify WIC-approved items? ☐ Yes ☐ No
15. Number of registers used for WIC transactions at the store: Total number registers:
16. Identify the types of staple foods sold at the store. Staple foods do not include prepared foods or accessory foods such as candy, condiments, spices, tea, coffee, or other drinks. Staple foods include but are not limited to: (Check ALL that apply to your store)
☐ Infant formula and cereal ☐ Fresh fruit and vegetables
☐ Eggs, milk, cheese, other dairy ☐ Canned and frozen fruit and vegetables
☐ Adult cereals and juices ☐ Poultry and other fowl (chicken, turkey, etc)
☐ Breads and baked good ☐ Fish and other seafood
☐ Rice, pasta, chips, cookies, crackers, etc ☐ Meat (beef, pork, lamb, etc)
17. In the next year, is it expected that more than 50% of the store’s total food sales will come from redeeming eWIC food benefits? ☐Yes ☐No
18. If any incentives, giveaways, raffles, and/or other free merchandise are provided at no charge to eWIC cardholders only, please describe these promotions and their associated cost. Use additional pages as needed.
☐ Check here if no incentives, giveaways, raffles, and/or other free merchandise are provided to eWIC cardholders only
19. Are eWIC cardholders allowed to pay the amount that exceeds the Cash Value Benefit balance, including sales tax, when purchasing fresh, frozen, and/or canned fruits and vegetables?
☐Yes ☐No
The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at . Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
I, the undersigned, do hereby assert that all of the information that I have provided as part of this supplemental form is true and accurate. I understand that providing false, inaccurate, incomplete information and/or no response within the identified due date may result in the termination of my store’s WIC Program authorization. Furthermore, I acknowledge that the information provided to the WIC Program may require supporting documentation be submitted to the Program in order to verify my responses.
Authorized Agent Name: Title:
Authorized Agent Signature: ______Date:
For Agency Use Only:
WIC ID: ______Assigned Date: ______Assigned By: ______
Application keyed by: ______Keyed date: ______