WIC-35 Family Certification Form

1 Name of Applicant or Parent/Guardian #1 (Nombre del solicitante o del padre/tutor #1)First (Primer nombre)Last (Apellido) Family Certification FormTelephone Number (Tel fono)Applicant/Parent/Guardian (Solicitante/padre/tutor) Family ID Date of Birth (Fecha de nacimiento)MM DD YYYYH ousehold SizeDate of Birth (Fecha de nacimiento)MM DD YYYY Identification Method01 Birth Certificate02 Hospital Records03 Baptismal Certificate04 Marriage License05 Driver s License06 WIC Identification Card07 Immunization Card08 School / Employee ID Card09 Military ID Card10 Official ID12 Passport / Immigration Record13 Other _____P/G #1P/G #2 LanguageEN ___EnglishSP ___SpanishVT ___VietnameseKO ___KoreanGR ___GermanLA ___LaotianAS ___ASLOT ___OtherMFMFYNOut-of-State TransferMailing Address (Direcci n postal)Mailing Address (Direcci n postal) Street (Calle)Apt # (Apt.)

2 #)City (Ciudad)Zip Code (C digo postal)Optional (Opcional)Residence Address (only if different from mailing) [Domicilio (solo si es diferente de la direcci n postal)] Street (Calle)Apt # (Apt. #)City (Ciudad)Residency01 Utility / Credit Card Bill02 Rent Receipt / Agreement03 Business Letter / Gateway04 Letter + Proof / WIC-R02 Sec C05 Voter-registration Card06 Property-tax Receipt07 Map + WIC-R02 Sec B08 Third-Party Verifier / WIC-R02 Sec A09 Shelter10 Homeless (WIC-19E)Census TractContact Name (Nombre de contacto) Family IncomeGateway A ____TANFF ____SNAPM ____MedicaidN ____NoneNon-Gateway Income MethodIncome Clerk User IDDateMM DD YYYYORM onthly IncomeIndicator (Y/N)CommentsPANG ateway Income Method16____YTBC 23 ____126617____1009 25 ____1000-B18____1866-A 27 ____Other19____RN 68-A _____20____1017 28 ____RN 6821____1027-A 29 ____TF000122____1122 30 ____TF0002 FosterYNMigrantYNMilitaryYNHomelessYNMid dle (Segundo nombre)Name of Parent/Guardian #2 (Nombre del padre/tutor #2)First (Primer nombre)Middle (Segundo nombre)Last (Apellido)Social Security Number (N mero de Seguro Social)Social Security Number (N mero de Seguro Social)Sex (Sexo)Sex (Sexo)Phone Number (Tel fono) Area Code (Clave del rea)Extension (Extensi n)Zip Code (C digo postal)Optional (Opcional)

3 01____Checkstubs02____Child Support03____Statement from Employer04____WIC 19a05____WIC 19b / H1028 Emp Ver06____SEU07____WIC-3208____Bank Statement09____Tax Return / IRS 104011 ____Other _____Applicant s or Parent s/Guardian s or Authorized Adult s Signature (Firma de solicitante o padre/tutor o del adulto autorizado)Date (Fecha) Household Security s Name and Address (physical or city) and/or WIC form Number (if applicable) Different pay frequency/Annual: Paid weekly X by 52 Paid every 2 weeks X 26 Paid twice monthly X 24 Paid monthly X 12 Same pay frequency: weekly, every 2 weeks, twice monthly, monthlySEUA/P/G #1P/G #2 Participant #1 Participant #2 Participant/OtherParticipant/OtherPartic ipant/OtherParticipant/OtherParticipant/ OtherParticipant/OtherParticipant/Other Annual Total Total Annual total divided by 12 Determine annual total and divide by 12orIncome Checked byStaff SignatureTitleDateFOR WIC STAFF USE ONLYq SEU must meet the requirements in WIC Policy (a) The unit usually purchases or intends to purchase, and prepare food separately.

4 (b) The unit meets the minimum income requirements for an SEU as listed in WIC Policy Gateway Verification Client ID or Case #: _____q By Phone Contact Name: _____q Automated Phone No.: _____q Online1) Compare Total to Income Guidelines .. 2) Monthly income to be entered in TWIN and other side of WIC-35 .. 1a) Meets Income Guidelines Yes q No q2112ororWIC Program Income ScreeningDisclosure of your Social Security number and that of your dependents is voluntary and WIC services will not be denied if you fail to do so. Social Security numbers are collected in accordance with 42 405(c)(2)(C)(i), (d)(2)(v) and WIC Policy CS: to verify information you have provided and to guard against dual participation as required by (l). I hereby state that neither my dependents nor I currently receive benefits from another clinic.

5 I also agree that I (we) will not receive WIC benefits from more than one clinic or State WIC Program during the same period. I understand that receiving dual benefits is considered fraud. Receiving dual benefits may subject me to:1. repaying in cash the value of food benefits improperly issued to me and/or my dependent(s)2. prosecution under state and federal laws, and3. being disqualified from participating in signing this form , I certify that all 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. WIC program officials may verify information including income and date of birth. I understand that intentionally making a false or misleading statement or intentionally omitting or withholding facts may result in my paying the state, in cash, the value of food benefits improperly issued and that I and/or my household members can be removed from WIC or criminally prosecuted or both.

6 In accordance with Federal civil rights law and Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on 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 with disabilities who require alternative means of communication for program information ( Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

7 Additionally, program information may be made available in languages other than file a program complaint of discrimination, complete the USDA Program Discrimination Complaint form , (AD-3027) found online at: , and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form . To request a copy of the complaint form , call (866) your completed form or letter to USDA by:(1) mail: Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW W ashington, 20250-9410;(2) fax: (202) 690-7442; or(3) email: institution is an equal opportunity 2014. All rights reserved. Stock no. WIC-35 Rev. 12/14 Visit our website at