Food items:

To complete this attachment, insert the normal shelf price (not sale price) of each of the following food items that are normally stocked and actually in the store. Provide prices only for the exact size listed. Leave the price line blank if the item is not currently stocked. Stores must meet minimum stocking requirements to be considered for authorization. Do not write in brand names for any food items except where asked. Refer to your Approved Food List as needed.

A. MILK:
Gallons / Lowest Price / Highest Price
Whole or Vitamin D / $ / gallon / $ / gallon
Reduced fat 2% / $ / gallon / $ / gallon
Low Fat ½% to 1% / $ / gallon / $ / gallon
Skim / $ / gallon / $ / gallon
½ Gallons
Reduced fat 2% / $ / ½ gallon / $ / ½ gallon
Low Fat ½% to 1% / $ / ½ gallon / $ / ½ gallon
Fat Free/Skim / $ / ½ gallon / $ / ½ gallon
Do you have at least 12 gallons total of whole, low fat, and skim milk in gallons on hand? Yes No
Highest Price: / Highest Price:
Lactose free / $ / quart / Powdered / $ / 9.6 oz.
Lactose free / $ / ½ gallon / Powdered / $ / 25.6 oz.
Sweet Acidophilus / $ / ½ gallon / 8th Continent Soymilk Original
Evaporated / $ / 12 oz. can / $ / ½ gallon
B. CHEESE (block, cubed, crumbled, shredded, sliced, stick, or string). No cheese food:
Highest Price - 8 oz. / Highest Price - 16 oz.
American / $ / $
Cheddar / $ / $
Colby / $ / $
Colby-Jack / $ / $
Mozzarella / $ / $
Monterey-Jack / $ / $
Provolone / $ / $
Swiss / $ / $
Do you have at least 3 pounds and 2 kinds of the above cheese on hand? Yes No
C. EGGS DOZEN: Highest Price / White / Brown
Regular Jumbo / $ / $
Regular Large / $ / $
Regular Medium / $ / $
Do you have at least 3 dozen eggs on hand? Yes No
D. CANNED BEANS: (list can size: Black, Garbanzo (Chickpeas), Great Northern, Kidney, Navy, Refried fat free)
Lowest priced variety: / List 2 varieties and sizes / Highest priced variety: / List 2 varieties and sizes
$ / oz. / $ / oz.
$ / oz. / $ / oz.
E. DRY BEANS, PEAS, AND LENTILS: (16-oz. bags without added flavors)
Lowest priced variety: / Highest priced variety:
$ / 1 lb. / $ / 1 lb.
Do you have at least 2 kinds of dry beans for a total of 3 pounds in 1-pound bags or 128 ounces of canned beans or a combination of 2 pounds dry and 64 ounces canned on hand? Yes No
F. FISH: (packed in water or oil; Sardines may be flavored) / Lowest Price / Highest Price
Light Tuna: / 5 oz. can / $ / $
12 oz. can / $ / $
oz. pouch / $ / $
oz. pouch / $ / $
Pink Salmon: / oz. pouch / $ / $
oz. pouch / $ / $
oz. can / $ / $
oz. can / $ / $
Sardines: / 3.75 oz. can / $ / $
15 oz. can / $ / $
G. GRAINS: List most expensive / Specify brand from the food List
Bread (Whole Grain/Wheat) / $ / 16-oz. loaves
Tortillas (Soft corn or whole wheat) / $ / 16 oz.
Rice (Brown) / $ / 14 -16-oz. bag
Do you have at least 10 of the 16-oz. loaves of whole grain/wheat bread on hand? Yes No
H. REGULAR PEANUT BUTTER (18-oz. jars only, smooth (creamy) or crunchy; no spreads):
Lowest price brand: / $
Highest priced brand: / $
Do you have at least 5 jars (18-oz.) of peanut butter on hand? Yes No
I. CEREAL (Note: List the size of all approved cereals you stock, 10-ounce minimum size):
National Brands:
General Mills:
Cheerios® Regular / $ / oz. / $ / oz.
Cheerios® Multi Grain / $ / oz. / $ / oz.
Wheat Chex / $ / oz.
Corn Chex / $ / oz.
Rice Chex / $ / oz.
Kix® (regular) / $ / oz. / $ / oz.
Honey Kix® / $ / oz.
Total (regular) / $ / oz. / $ / oz.
Wheaties® (regular) / $ / oz. / $ / oz.
Kellogg’s:
Crispix® / $ / oz. / $ / oz.
Corn Flakes / $ / oz. / $ / oz.
Mini Wheats® Big Bite / $ / oz. / $ / oz.
Mini Wheats® Bite Size / $ / oz. / $ / oz.
Mini Wheats® Bite Size / $ / oz. / $ / oz.
Mini Wheats® Unfrosted / $ / oz.
Rice Krispies® / $ / oz. / $ / oz.
Special K (Original) / $ / oz. / $ / oz.
Post®
Grape Nuts / $ / oz. / $ / oz.
Grape Nuts Flakes / $ / oz. / $ / oz.
Banana Nut Crunch® / $ / oz.
Honey Bunches of Oats®:
Honey Roasted / $ / oz. / $ / oz.
with Almonds / $ / oz. / $ / oz.
with Cinnamon Clusters / $ / oz. / $ / oz.
Malt-O-Meal:
Frosted Mini Spooners® / $ / oz. / $ / oz.
Crispy Rice® / $ / oz. / $ / oz.
Quaker®:
Life® / $ / oz.
King Vitaman® / $ / oz.
Oatmeal Squares / $ / oz. / $ / oz.
Oatmeal Squares Cinnamon / $ / oz. / $ / oz.
HOT CEREALS:
Malt-O-Meal / $ / oz. / $ / oz.
Quaker® Instant Oatmeal (regular only) / $ / oz.
Co Co® Wheats / $ / oz. / $ / oz.
Cream of Wheat (1, 2½, or 10 Minute) / $ / oz. / $ / oz.
Cream of Wheat Whole Grain / $ / oz. / $ / oz.
Do you have 20 boxes, 6 kinds, 1 cooked, and 1 whole grain of the above cereals on hand? Yes No
J. FRESH FRUITS AND VEGETABLES (Note: Organic fresh fruit and vegetables are allowed.):
Any variety of fresh fruit and whole or cut vegetable, except white potatoes, without added sugars, fats, or oils;
(orange yams and sweet potatoes are allowed.)
Do you have at least $30 worth of fresh fruits and vegetables and two varieties of each? Yes No
NOTE: All juice categories below must be 100% juice and a minimum of 120% vitamin C.
K. JUICE (64 oz. containers only):
Shelf Stable Orange or Grapefruit juice,
100% juice and at least 120% vitamin C; list brands:
$
$
$
Click appropriate box(es):
Apple juice / Hy Top / $
Indian Summer / $
Lucky Leaf / $
Musselman’s (Premium only) / $
Seneca / $
Grape juice / Welch’s purple, red, or white only / $
Old Orchard 100% juice, purple or white / $
Juicy Juice, any flavor / $
Old Orchard 100% juice (no Apple Cider) / $
Tomato juice
Campbell’s: Regular or Low Sodium / $
Vegetable juice
V-8 juice: Regular or Low Sodium / $
Refrigerated Orange or Grapefruit juice, (64-oz. ONLY; 100% juice and at least 120% vitamin C)
List brands:
$
$
$
$
$
Do you have at least 15 containers and 3 kinds of juice in an approved 64 oz. size on hand? Yes No
L. JUICE CONCENTRATES:
(FROZEN)
Orange or Grapefruit juice, 100% juice and at least 120% vitamin C
List brands (11.5 - 12 oz. size):
$
$
Apple juice
Kroger / $
Seneca / $
Other juice flavors
Dole 100% juice, any flavor / $
Old Orchard (any green tab) / $
Welch’s 100% juice (any yellow tab) / $
(SHELF STABLE)
Juicy Juice, any flavor / $
Welch’s 100% juice, any flavor / $
Do you have at least 5 cans and 2 kinds of 11.5 - 12 oz. juice concentrate on hand? Yes No
M. INFANT CEREAL any grain or multi-grain (8-oz. box without fruit)
List brands:
$
$
$
Do you have at least 8 boxes and 2 kinds of infant cereal on hand? Yes No
N. Beech Nut Baby Food
4-oz. glass jars, Fruits and Vegetables / $
2.5-oz. glass jars, Meat, may include broth or gravy / $
Do you have at least 96 of the 4-oz. jars of WIC approved baby food (2) varieties each of fruits and vegetables? And, 31 of the 2.5-oz. glass jars of WIC approved baby food (meat only, may include broth or gravy) on hand? Yes No
O. INFANT FORMULA:
Is your store also a pharmacy? Yes No
If No, list below the shelf price of the formulas you regularly stock.
If Yes, have your pharmacy list below your price for ALL formulas.
This application will not be processed without these prices. Authorized pharmacies must provide all prescribed formulas within 2 working days. Also, please review the WIC formulary list at www.wic.in.gov..
Can you obtain any of these special order formulas within 2 working days? Yes No
Who is the WIC contact for special order formula at your store?
()-
Name / Title / Phone Number / Email address
List ‘PER CAN’ prices except where other units are indicated and click the box next to the price of the items that you stock. (NOTE: Bolded items are required to be in stock.)
Powder size
as specified / Ready to
Feed, 1 qt. / 13 oz. Liquid Concentrate / Case of 48
bottles, 2 oz. ea.*
Gerber Goodstart Gentle / $ / 12.7 oz. / $ / $ 12.1 oz. / $20 cal*
Gerber Goodstart Protect / $ / 12.4 oz. / $ / $20 cal*
Gerber Goodstart Soy / $ / 12.9 oz. / $ / $ 13 oz. / $*
Enfamil AR / $ / 12.9 oz. / $ / $ 13 oz. / $*
Enfamil Nutramigen with Enflora / $ / 12.6 oz. / $ / $ 13 oz. / $*
*Enfamil Nutramigen AA / $ / 14.1 oz.*
*Enfamil Nutramigen AA / $ / Case of 4*
Enfamil Pregestimil / $ / 16 oz.
*Enfamil Pregestimil 20 cal / $*20 cal
*Enfamil Pregestimil 24 cal / $*24 cal
Enfamil EnfaCare / $ / 12.8 oz. / $ / $*22 cal
*Enfamil Premature fortified 20 cal / $*20 cal
*Enfamil Premature fortified 24 cal / $*24 cal
Enfagrow Premium Toddler / $ / 24 oz. / $
Enfagrow SoyToddler / $ / 24 oz.
Enfagrow Gentlease Toddler / $ / 24 oz.
Pediasure (any flavor) / $ / 6 – 8 oz bottles
Pediasure with fiber (any flavor) / $ / 6 – 8 oz bottles
*Items we do not recommend that you stock. We suggest that chain stores keep these items in their distribution centers for quick delivery at a reasonable price. This is not a complete list of all prescription formulas. It includes the most commonly prescribed WIC formulas and we recommend that large stores stock as many as possible.
Do you have at least the following quantities of formula on hand?
Yes No 20 cans of Gerber Goodstart Gentle powder 12.7 oz.
Yes No 12 cartons of Gerber Goodstart Gentle concentrate 12.1 oz.
Yes No 5 cans of Gerber Goodstart Protect powder 12.4 oz.
Yes No 5 cans of Gerber Goodstart Soy powder12.9 oz.
List suppliers:
Groceries:
Company Name / Address / City / State / Zip Code
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Contact Name / Phone Number / Email address
Formula Items:
Company Name / Address / City / State / Zip Code
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Contact Name / Phone Number / Email address

In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from discrimination based on race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write: USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington D.C. 20250-9410, or call 800-795-3272 (voice) 202-7206382 (TTY). USDA is an equal opportunity provider and employer.