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2. WIC Application Form
   Only Chisago County residents may apply. For residents of other Minnesota counties, please call 1-800-942-4030.
4. Contact Chisago County WIC at 651-213-5206 with any questions about your application.
6. Applicant's Name*
7. Birth Date*
   Birth Date
9. Email
10. Contact Phone*
    Remember to include area code
12. Address*
14. City*
15. State
16. Zip Code
20. Household Size*
    People in the same household are related or non-related and share in consumption of the same goods and services. If you are applying for your foster children, each foster child is considered family of one. Pregnant women count as two. Include any children that you are paying child support for.
22. Please list any household members who are pregnant or postpartum women and children under 5.
24. Last Name, First Name
25. Birth Date
    Birth Date
26. Sex
    -- Select One --FemaleMale
28. Due Date / Delivery Date
    Due Date / Delivery Date
29. Breastfeeding?
    -- Select One --YesNo
33. Last Name, First Name
34. Birth Date
    Birth Date
35. Sex
    -- Select One --FemaleMale
39. Last Name, First Name
40. Birth Date
    Birth Date
41. Sex
    -- Select One --FemaleMale
45. Last Name, First Name
46. Birth Date
    Birth Date
47. Sex
    -- Select One --FemaleMale
51. Last Name, First Name
52. Birth Date
    Birth Date
53. Sex
    -- Select One --FemaleMale
57. Has anyone above ever been on WIC before?*
    -- Select One --YesNo
58. If yes, when?
59. Where?
61. If yes, was a different name used?
    -- Select One --YesNo
62. Maiden name
64. May we contact this program for health and nutrition information?
    -- Select One --YesNo
66. Please check ALL services that the household receives:

    1. Minnesota Family Investment Program (MFIP)
    2. Supplemental Nutrition Assistance Program (SNAP)
    3. Head Start
    4. Fuel Assistance
    5. Free or Reduced Priced School Lunch Program
    6. Medical Assistance (MA)
    7. Minnesota Care (MnCare)
    8. Social Services Information System (SSIS) - Applies ONLY to person receiving
    9. Tax Equity and Financial Responsibility Act of 1982 - Medical Assistance (TEFRA MA) - Applies ONLY to person receiving
68. STOP: If Applicant is CURRENTLY receiving services listed above, you automatically qualify for WIC and do NOT need to fill out INCOME information.
72. Financial Information: Please report gross income (before taxes)
    (Annual income based on federal tax forms: Form 1040 - line 11b)
74. Income #1: Hourly wage
    If no income, put 0
75. Hours per week
76. Annual Gross Income (before deductions/taxes)
78. Income #2: Hourly wage
79. Hours per week
80. Annual Gross Income (before deduction/taxes)
82. Do you receive child support?
83. Do you receive Social Security Income?
85. Do you receive Veterans or other pensions?
86. Do you receive Tribal / Band payment?
88. Do you receive Unemployment, Compensation or Disability?
89. Do you receive rental income from tenants?
91. Is there any other income in your household?
93. Certification*

    1. I certify.

    I certify that the information I have provided is correct to the best of my knowledge. I understand that intentionally giving false or misleading information will result in my not receiving WIC benefits.
95. Minnesota WIC Program Non-Discrimination Statement
    Minnesota WIC Program Non-Discrimination Statement
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field