Forms
WIC Program Resources for Local Agencies
- Notes - Downloading Different Types of Forms (Excel, Word, PDF)
- 2011 Claim for Reimbursement Form for Single Entity Agencies
- 2012 Claim for Reimbursement Form for Single Entity Agencies
- 2012 Claim for Reimbursement Form for Multi-County CHB Agencies
- 2013 - WIC Peer Breastfeeding Support Program Claim for Reimbursement FFY13
- Ad-Hoc Reports Assistance Request
- Benefit Stock Order Form for HuBERT
- Claim Form for Breastpump Purchase Reimbursements
- Exhibit 2-C: Request of Increase in Administrative Funds
- How to Create a CFH Account and Request Access to Forms on WIC Tools
- HuBERT Change Request Form
- Recycle Laser Printer Toner Cartridge Mailing Label
- Report Faulty Printer Replacement Form
- Request for Equipment (former Automation Equipment Request Form)
- Request for Supplies (former Request for Supplies from Covansys)
- Special/Medical Infant Formula Order Form
- Store Incident Report Form
- WIC Materials Order Form for Local Agencies
- WIC Outreach Materials Order Form for Local Agencies
Notes - Downloading Different Types of Forms
(Excel, Word, PDF)
Excel Forms
Excel forms should be saved to your computer before opening. Click the Save button on the File Download message and select where the file should be saved. Once the file is saved (it will automatically save as an Excel file), you can complete the form in Excel.
Word Forms
Word files should be saved to your computer before opening. Click the Save button on the File Download message and select where the file should be saved. Once the file is saved (it will automatically save as a Word file), you can complete the form in Word. Please fax or e-mail the form as indicated.
Word Forms with Fillable Fields
Word forms with fillable fields should be saved to your computer before opening. Click the Save button on the File Download message and select where the file should be saved. Once the file is saved (it will automatically save as a Word file), you can complete the form in Word. (To select a checkbox, double click on it and select the Checked radio button in the Default Value section. Click the OK button to exit.)
PDF Forms
PDF forms should be printed and completed manually. Please fax or e-mail the form as indicated.
- 2011 Claim for Reimbursement Form for Single Entity Agencies - Excel Form (1MB)
- 2013 - WIC Peer Breastfeeding Support Program Claim for Reimbursement FFY13 - EXCEL File (82KB)
- Ad-Hoc Reports Assistance Request - Automated Form
Note: Local Agencies can use this form to submit an on-line request for data information or assistance with reports. Please select Query/Report from the Type drop-down list.
- Benefit Stock Order Form for HuBERT - Automated Form
- Claim Form for Breastpump Purchase Reimbursements - PDF: 53KB/1 pg (Exhibit 2-H in MN Operations Manual)
- Exhibit 2C: Request for Increase of Administrative Funds - revised September 2009
- Exhibit 2-C - WORD Form (28KB/2 pages)
- Exhibit 2-C - PDF - print only (13KB/2 pages)
- HuBERT Change Request Form - Automated Form
Note: Local Agencies can use this form to suggest potential changes to HuBERT, including: software changes, nutrition education topics, and drop-down list options. The form can also be used to request data information or assistance with reports.
- Recycle Laser Printer Toner Cartridge Mailing Label (PDF: 108KB/1 page)
Note: Local Agencies can use this form as a mailing label to recycle laser printer toner cartridges. Print this page and affix it to the box containing the used laser printer toner cartridge you want to return for recycling. Mail the package by US Mail. Please do not use this label to return defective toner cartridges.
- Report Faulty Printer Replacement Form - Automated Form
Note: Use this form to report a change in printer inventory at your local agency. The form is only necessary for printers that were replaced due to failure.
- Request for Equipment (former Automation Equipment Request Form) - Automated Form (Exhibit 9-C in MN Operations Manual)
Note: Local Agencies can use this form to order computer equipment and peripherals on-line.
- Request for Supplies (former Request for Supplies from Covansys) - Automated Form (Exhibit 9-A in MN Operations Manual)
Note: Local Agencies can use this form to order miscellaneous supplies such as address labels, printer toner, and printer photoconductors.
- Special/Medical Infant Formula Order Form
Note: Local Agencies can use this form to order a special formula from the State WIC office.
- WORD form - fill-able fields (32KB/1 page)
- PDF form - print only (12KB/1 page)
Note: Local Agencies can use this form to submit issues with WIC vendors/stores.
- WIC Materials Order Form for Local Agencies - Automated Form
(Former "WIC Materials in English Order Form" and "Translated & Targeted WIC Materials Order Form".)
Note: Local Agencies can use this form to order WIC materials such as Brochures, Handouts, Videos, Posters, Administrative Forms/Letters and Staff Resources, including those translated into other languages.
- WIC Outreach Materials Order Form for Local Agencies - Automated Form
Note: This form can be used to order WIC Outreach Brochures, Fact Sheets, Posters and Magnets.
