WIC Eligibility Questionnaire
Answer the following questions to help determine your eligibility for the WIC program.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Other
Are you currently pregnant, breastfeeding, or postpartum?
*
Pregnant
Breastfeeding
Postpartum (recently had a baby)
None of the above
Number of people in your household (including yourself)
*
List the ages of all children in your household under 5 years old
*
Monthly gross household income (before taxes)
*
Are you or anyone in your household currently receiving any of these benefits?
*
Medicaid
SNAP (Food Stamps)
TANF (Temporary Assistance for Needy Families)
None of the above
What best describes your relationship to the child(ren) under 5 in your household?
*
Parent
Legal Guardian
Foster Parent
Other
Do you have proof of residency in your state (e.g., utility bill, lease, official mail)?
*
Yes
No
Check Eligibility
Should be Empty: