I Agree To:
• Attend and be on time for all appointments.
• Let WIC staff know in advance if I cannot keep an appointment.
• Provide accurate and correct information to WIC.
• Let the WIC staff know if my address, phone number or income changes, if I am going to move away or if I no longer have custody of the child.
• Handle my eWIC card carefully as replacing the card can take several days.
• Report eWIC Cards that are lost, stolen or destroyed.
• Follow the shopping guidelines for using WIC benefits as specified in the Program Booklet.
• Treat WIC staff and retail staff with respect and courtesy.
• Train my authorized representatives and proxies on WIC and eWIC Card procedures and policies. I am accountable for their actions.

I Understand That:
• WIC will give me benefits to buy certain foods from WIC authorized retailers each month and it is important that the benefits are picked up on time. If benefits are not picked up for two months in a row, I may be removed from the Program.
• The local WIC program will make nutrition education and referrals to health services available to me and/or my child. I am encouraged to use these services.
• My WIC information may be released to other programs and entities to determine eligibility, conduct outreach, enhance health education, streamline administrative procedures or access and evaluate participant health care
needs and outcomes. For a list of programs or entities that may receive your information, please ask WIC staff.
• Receiving benefits from more than one WIC clinic at a time is illegal (dual participation).
• I may lose my WIC benefits if I or an authorized individual sell my eWIC Card; return WIC foods for cash or non-WIC foods; sell, trade, or give away WIC foods; buy nonWIC foods; use an unauthorized retailer; or verbally abuse WIC or retail staff. I also may be required to repay benefits.
• Coordination with medical payors and other programs that provide or reimburse for formula is required. If I am receiving formula from a medical payor, I will inform WIC staff.
• Standards for eligibility and participation in the WIC Program are the same for everyone, regardless of 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.
• I have 60 days to appeal any decision made by the local agency regarding my eligibility for the Program. A fair hearing will be conducted by a fair and impartial official according to 246.18 and applicable portions of Title 2, Chapter 4 Montana Code Annotated, whose decision will rest solely on the evidence presented at the hearing and statutory and regulatory provisions governing the WIC Program in Montana.
I have been advised of my rights and responsibilities under the Program. I certify that the information I have provided for my eligibility determination is
correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or  withholding facts may result in paying the State agency, in cash, the value of food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law.

This institution is an equal opportunity provider.