Signature Authorization Form Page 2
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2NEW YORK STATE DEPARTMENT OF HEALTH
Authorization Form
Division of Nutrition/WIC Program
If you would like to authorize another person to represent you at times when you are
For Office Use Only
Unable to attend WIC appointments or redeem food instruments, please check either
Validation Date:
Parent/Spouse/Partner, Representative or Proxy. You are allowed to have up to two
Persons represent you but this is not required.
Void Date: ____________________________
This form does not allow for the release of WIC records.
Participant’s Initials: ______________________
Participant Name(s)
Individual WIC I.D. Numbers
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
________________________________________________
___________________________________________
Parent/Spouse/Partner
Representative
•
•
has the same rights under the WIC program as the enrolling
must be someone responsible for the primary care of the
parent/spouse/partner
participant and able to provide information on the eating
•
habits and medical condition of the participant(s)
can authorize a Representative or Proxy
•
•
can sign all required forms
can sign all required forms
•
•
can represent you at your children’s certification
can represent you at your certification appointments
•
appointments
can represent you at your children’s certification
•
can represent you and/or your children at nutrition
appointments
•
education appointments
can represent you and/or your children at nutrition
•
can pick up and redeem your food instrument
education appointments
Proxy
•
can pick up and redeem your food instruments
•
can represent you and/or your children at nutrition
education appointments
•
can pick up and redeem your food instruments
_____________________________________________________________________
Verification of Correct Information
Signature
_____________________________________________________________________
Name (please print)
Initial/Date
Initial/Date
_____________________________________________________________________
Address
Initial/Date
Initial/Date
_____________________________________________________________________
City
State
Zip Code
Initial/Date
Initial/Date
_____________________________________________________________________
Phone #
Initial/Date
Initial/Date
I have instructed the above authorized parent/spouse/partner, representative or proxy on the rules and regulations of the WIC
program including proper use of food instruments at redemption locations. I understand that I am liable for improper or fraudulent
use of the WIC program by said person..
Signature of Participant/Parent/Guardian (sign only after form is completed)
Date
DOH-141 (12/09)
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