This institution is an equal opportunity provider. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. Submit your completed form or letter to USDA by: To request a copy of the complaint form, call (866) 632-9992. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. Clients sign the WIC Statement of Income Form (PDF) when proof of income doesn’t exist, for example when the person has no income, works for cash or income documentation was destroyed in a house fire or natural disaster. Additionally, program information may be made available in languages other than English. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Completion of this form is required to determine WIC eligibility and any personally identifiable information.

If your income has been affected by recent events, and you are pregnant or have a child under 5, WIC can help provide nutritious foods and more resources to keep your growing family healthy. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g. Participation in the WIC program is voluntary. WIC services are available to all eligible families affected by COVID-19. In accordance with Federal civil rights law and U.S. This form maybe used to refer patients to the WIC Program and to communicate changes in patient health information.

Wic form