Wic Prescreen Form - Sherburne County Health And Human Services

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Sherburne County Health and Human Services
WIC Program
13880 Business Center Drive NW
Elk River MN 55330-1692
Phone: 763-765-4116 or 1800-433-5239
Fax: 763-765-4154
Email: WIC@co.sherburne.mn.us
WIC Prescreen Form
Name _____________________________________________
Home phone ____________ Cell phone____________
Address ___________________________________________
City ___________________ Zip Code ____________
Total number of persons in household: __________________
People in the same household are related or non-related and share in consumption of the same goods and services. If you are applying for your foster children, each
foster child is considered family of one. Pregnant women count as two. Include any children that you are paying child support for.
Please list any household members who are pregnant or postpartum women and children under age 5.
Due Date
MA
Last name, First name
Sex
Birth Date
MA number
Delivery Date
MN Care
Mother
F
/
/
Y / N
Child 1
M / F
/
/
Y / N
Child 2
M / F
/
/
Y / N
Child 3
M / F
/
/
Y / N
Child 4
M / F
/
/
Y / N
Has anyone above ever been on WIC before? Y / N
If yes, when? _______________ Where? ______________
May we contact this program for health and nutrition information? Y / N
Please check all services that the household receives:
 Minnesota Family Investment Program (MFIP)
 Food Stamps/Supplemental Nutrition Assistance Program (SNAP)
 Head Start
 Fuel Assistance
 Free or Reduced Priced School Lunch Program
Financial Information: Please report gross income (before taxes)
Income #1: Hourly wage________Hours/wk_______Weekly gross______Monthly gross ______ Annual Income_______
Income #2: Hourly wage________Hours/wk_______ Weekly gross______Monthly gross______ Annual Income_______
Do you receive child support?
$____________/month
Do you receive Social Security Income?
$____________/month
Do you receive Unemployment, Comp or Disability?
$____________/month
Do you receive Veterans or other pensions?
$____________/month
Do you receive Tribal or Band payment?
$____________/month
Do you receive rental income from tenants?
$____________/month
Is there any other income in your household?
$____________/month
WIC is an equal opportunity provider
Updated 7/12

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