MN WIC Program
Local Agency Forms
HuBERT Benefit Stock Order Form
Automated Form - Local agencies can use this form to submit on-line quarterly or emergency orders for benefit stock
Local Agency HuBERT Change Request Form
Use to submit suggestions for HuBERT software changes, drop-down list options, nutrition education topics/materials; to add/update/remove medical home clinics, referral organizations and WIC clinics; and request assistance with ad-hoc reporting.
Manual Certification - WIC Proof of Eligibility (WORD)
For use if HuBERT system or Internet is down and cannot perform electronic certification - household information
Manual Certification - Infants and Children (Required Fields) (WORD)
For use if HuBERT system or Internet is down and cannot perform electronic certification - information for infants and children
Manual Certification - Women (Required Fields) (WORD)
For use if HuBERT system or Internet is down and cannot perform electronic certification - information for women
Recycle Laser Printer Toner Cartridge Mailing Label (PDF)
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 - 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 (Exhibit 9-C in MN Operations Manual)
Automated Form - Local Agencies can use this form to order computer equipment and peripherals on-line.
Request for Supplies (Exhibit 9-A in MN Operations Manual)
Automated Form - Local Agencies can use this form to order labels, printer cartridges, printer imaging units, and photoconductor replacements on-line.
Rights & Responsibilities (Laminated Copy) - Link to Order Form
Link to Local Agency WIC Materials Order Form where a laminated copy of the Rights & Responsibilities Form can be ordered.
WIC Household Food Instrument Register (WORD)
For use if staff cancel out of signature screen before participant can sign for benefits received
WIC Household Manual Certification Register (WORD)
For use if staff cancel out of signature screen before participant can sign for Rights & Responsibilities or before staff can sign for having determined eligibility