AFFIRMATION OF IDENTITY, RESIDENCY, INCOME, OR BENEFIT LOSS 8/23

Participation in WIC is voluntary. Personally identifiable information is used to determine WIC eligibility and may be disclosed to others only as allowed by state and federal laws.

Date

Guardian

Family ID

Participant Name

Participant ID

Participant Name

Participant ID

AFFIRMATION OF IDENTITYIINCOME/RESIDENCY: I understand that I must provide WIC with written documentation as proof of the total household income, my identity and residency to determine my eligibility for WIC benefits.

I cannot provide proof of my total household income because:

I affirm that the total gross income Including wages, child support, social security income, tips, workman's compensation, unemployment, etc is:

weeklyevery two weeksmonthlytwice a month

I cannot provide proof of my residency because:

I affirm my address is:

I cannot provide proof of my identity because:

Date of benefit loss:

Date

Describe how the food was destroyed:

By signing this form, I am certifying that the information I have provided is correct to the best of my knowledge. I understand that intentionally making a false statement or intentionally misrepresenting, concealing, or withholding facts may result in termination from the program; paying the state agency, in cash, the value of the food benefits improperly issued to me; and may subject me to civil or criminal prosecution under state and federal law.

Foods that are to be replaced and date of purchase:

SIGNATURE (Applicant/Participant/Guardian's)

Date

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign
Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

(1)

Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) Fax: (202) 690-7442; or

(2) Fax:

(833) 256-1665 or (202) 690-7442: or

(3) Email: program.intake@usda.gov

This institution is an equal opportunity provider.

F-40019 (8/2023)

AFFIRMATION OF IDENTITY, RESIDENCY, INCOME, OR BENEFIT LOSS