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Women Infants & Children (WIC) Application

  1. Women Infants and Children (WIC) Application

  2. This is my*

  3. Text Appointment Reminder Okay?

  4. This is my

  5. You, the Applicant are the:*

  6. Gender*

  7. Primary Language*

  8. Do you need an interpreter?

  9. Have you been on WIC before?*

  10. Eligibility Requirements

  11. Are you or any member of your family on MA or MN Care?*

  12. Are you or any of your family members on any of the following programs? *

  13. 1st Person's Income

  14. Overtime?*

  15. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?*

  16. Is there a second wage earner in your household? *

  17. 2nd Person's Income

  18. Overtime?

  19. Other Sources: Do you have other income from MFIP Workers' Comp, Social Security, Child Support, SSI, or other sources?

  20. Women

  21. Are you pregnant?*

  22. Are you breastfeeding?*

  23. Are you using formula?*

  24. Are there children under 5 in your household?*

  25. Gender

  26. Gender

  27. Gender

  28. Gender

  29. Gender

  30. Leave This Blank:

  31. This field is not part of the form submission.