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Form Wic-48 - Louisiana Women, Infant And Children (Wic) Special Supplemental Nutrition Program Form - Louisiana Department Of Health And Hospitals Page 2

LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS

OFFICE OF PUBLIC HEALTH NUTRITION SERVICES

Louisiana Women, Infant and Children (WIC) Special Supplemental Nutrition Program

(Include on back of WIC - 48, two-sided form)

WIC Supplemental Food Packages

WIC participants receiving special medical formula/foods will also receive food from the list below,

unless they are contraindicated.

Formula

Infants 0-3

Infants 4-5

Infants greater

Infants 6–12

months *

than 6 months *

months with

formula only *

Powder, (reconstituted)

Up to 870 fluid ozs

Up 960 fluid ozs

Up to 696 fluid ozs

Up to 960 fluid ozs

Concentrate (reconstituted)

Up to 806 fluid ozs

Up to 884 fluid ozs

Up to 624 fluid ozs

Up to 884 fluid ozs

Ready-to-feed

Up to 832 fluid ozs

Up to 896 fluid ozs

Up to 640 fluid ozs

Up to 896 fluid ozs

Infant Cereal

N/A

24 oz Infant Cereal

N/A

32 – 4oz Jars Baby

Baby Food Fruit and Vegetables

N/A

Food Fruits and

Vegetables

* Formula quantities provided are less if the infant is breastfed.

Children

Fully Breastfeeding

Pregnant and Partially

Postpartum

and Partially Breast

Breastfeeding Women

Women

Feeding Multiples

Women

910 ozs formula

13 quarts milk

21 quarts

19 quarts milk

13 quarts milk

1 pound cheese

2 pounds cheese

1 pound cheese

1 dozen eggs

2 dozen eggs

1 dozen eggs

128 ozs juice

144 ozs juice

96 ozs juice

36 ozs breakfast cereal

$6.00 fresh fruits and

$10.00 fresh fruits and

$8.00 fresh fruits and vegetables

$8.00 fresh fruits and

vegetables cash value

cash value voucher

vegetables cash value

voucher

18oz peanut butter OR

18oz peanut butter AND 16

18oz peanut butter and 16 ozs dried

18oz peanut butter OR

16ozs dried beans

ozs dried beans

beans

16ozs dried beans

2 pounds whole wheat

1 pounds whole wheat bread

1 pounds whole wheat bread or

N/A

bread or equivalent, or

or equivalent, or brown rice

equivalent, or brown rice

brown rice

N/A

30 ozs tuna or salmon

N/A

WIC – 48

Rev 5/09

Form Wic-48 - Louisiana Women, Infant And Children (Wic) Special Supplemental Nutrition Program Form - Louisiana Department Of Health And Hospitals Page 2

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