WIC Retailer Incident & Participant Complaint Form

WIC Retailer Incident & Participant Complaint Form

Complete the form below to report a complaint or concern about WIC stores and/or WIC shoppers. Include any additional information, such as store receipts, food pictures, etc. Please send to: Alyssa Thomas at alyssa.thomas@state.co.us or fax to (303) 756-9926.
Name of person/client reporting

First NameLast Name
Contact Phone Number

Area CodePhone Number
Identity of the person reporting (i.e. WIC shopper, store cashier, etc.)
Card number/PAN or FID #
Date of incident

MonthDayYear
Time of incident

:HourMinutesAM/PM Option
Store Name
WIC vendor ID #
Cashier Name
Cashier Description
Cross Streets/Intersection of Store
City
Local WIC Agency name or location
Other transaction information (i.e. details from receipt, foods purchased, store lane, etc.):
Please describe what happened (be specific):
Describe further action you are requesting from the State WIC Office
Additional information (store receipts, food pictures, etc.)

Upload a File

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Thank you for your cooperation. If you have further information regarding the incident, please call (303) 692-2448. If you have any questions or need this form in an alternate format, please call (303) 692-2400.
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