Wic Program Appeal Request Form -Alabama Department Of Public Health
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1ALABAMA DEPARTMENT OF PUBLIC HEALTH
WIC PROGRAM
APPEAL REQUEST FORM
STORE NAME: ____________________________________________________
VENDOR #:_________________________________
ADDRESS: _______________________________________________________
PHONE#:___________________________________
CITY: ___________________________ STATE: ________
ZIP: ___________
DATE: ______________
Food Instrument (FI) and/or Cash
Requested
Food Instrument (FI) and/or Cash
Requested
Include original or legal
Value Voucher (CVV) NUMBER(S)
Amount
Value Voucher (CVV) NUMBER(S)
Amount
image (copy) of FI/CVV and
receipt/journal transaction
with this form.
Mail the request to:
Alabama Department of Public
Health
Bureau of Family Health Services
WIC Division, Suite 1300
The RSA Tower
P.O. Box 303017
Montgomery, Al 36130-3017
Provide detailed explanation of how the error occurred: (Attach Additional Sheets if Necessary)
*The State WIC Office reserves the right to reduce the amount or deny payment on any request that is found to have an unsatisfactory explanation.
Outline Corrective Action Taken to Eliminate the Error: (Attach Additional Sheets if Necessary)
Signature: ______________________________________________________ Title:_________________________________________________
WIC Use Only
Date Returned:
Reason Returned to Vendor Unpaid
Encoding Error
Vendor Stamp Missing or Illegible
APPEAL DENIED
Redeemed Prior to First Day to Use
Signature Missing
DO NOT RESEND
Stale Dated
See Alabama WIC Program Vendor
Procedure Handbook
Request Received Past 90 Days of First Day to Use
Date
Allowed Purchase of Wrong Item
Appeal Request Form Not Included or Incomplete
(Form can be obtained on the Department’s website.)
Receipt/Journal Transaction Not Included
OTHER:
October 2014
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