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Forms are shaded grey Education shaded white WIC Directory of Publications and Forms July 2026 ADPH Form Description Revision Date Packaged Available From WIC-100/100S How WIC Can Help 06/26 Packs of 100 Document Library/Warehouse

WIC-101 Health Care Provider Guide booklet

04/26 individually Request from State WIC Office WIC-104 WIC Referral/Medical Information Form 08/20 -- Document Library

WIC-105 Data Update Request Form 08/26 -- Document Library

WIC-106 Shopper Push Notification Request Form

08/26 -- Document Library WIC-109 WIC Formula Request Form 07/26 -- Document Library

WIC-110 Certificate of Donated Formula 01/26 -- Document Library

WIC-111a WIC Formula Prescription for Infants 04/26 -- Document Library

WIC-111b WIC Formula Prescription for Children and Women 04/26 -- Document Library

WIC-112 Formula Log/Issuance Sheet 04/18 -- Document Library

WIC-114 Hospital Special Formula Notification 08/25 -- Document Library

WIC-115/115S Statement of Income Support (Spanish on Back) 07/25 -- Document Library

WIC-116/116S No Proof Form (Spanish on Back) 07/26 -- Document Library

WIC-117 Verification of Participation 07/24 -- Document Library

WIC-118/118S What to Bring to Your Appointment (Spanish on Back) 07/26 Pads of 100 Document Library/Warehouse WIC-154/154S Welcome, Baby! (Spanish on Back) 07/26 -- Document Library

WIC-157/157S Who is Eligible for WIC (Spanish on Back) 06/26 Packs of 100 Document Library/Warehouse

WIC-167/167S WIC Certification Process 04/26 Packs of 100 Document Library/Warehouse

WIC-264 Vendor Procedure Handbook 08/2026 -- State WIC Office

WIC-280/280S Food Safety Tips 02/23 Packs of 100 Warehouse

WIC-299/299S Caring for Yourself After Pregnancy Loss 04/24 Packs of 100 Document Library/Warehouse

WIC-308/308S What Should I Eat? Breastfeeding and Non- Breastfeeding Moms 02/24 Packs of 100 Warehouse WIC-331 Clinic Issuance/Inventory Sheet for Pumps/Pads 07/26 -- Document Library

WIC-331a Clinic Issuance/Inventory for BF Aids 07/26 -- Document Library

WIC-332 Inter-Clinic Breast Pump Transfer Form 02/23 -- Document Library

WIC-334 Combined Pump Issuance Form 01/26 -- Document Library