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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

WIC AND NUTRITION SERVICES

PARTIAL WIC FORMULA REDEMPTION

PART A. VENDOR USE ONLY

To be used only for formula, if the vendor does not have the entire quantity of formula issued on the WIC check and the customer

(WIC participant, guardian or proxy purchasing the formula) cannot travel to another store or return to the store at a later date. Enter the

information below where applicable. Fields must be copied directly from the WIC CHECK.

1. STORE NAME

2. FOUR (4) DIGIT WIC VENDOR NUMBER

3. PARTICIPANT NUMBER FROM WIC CHECK

4. PARTICIPANT NAME FROM WIC CHECK

5. WIC CHECK NUMBER

6. FULL NAME OF FORMULA AND SIZE OF CAN SHOWN ON WIC CHECK

7. TYPE

Liquid Concentrate

Powder

Ready To Use

8. LAST DATE TO USE

9. PURCHASE PRICE ENTERED ON WIC

10. # OF CANS PRESCRIBED ON WIC

11. # OF CANS GIVEN TO THE

CHECK

CUSTOMER

The undersigned store representative attests that the actual amount of formula provided to the customer is reflected in Box 11 of this

form and the WIC program was charged only for the amount of formula provided to the customer. Excessive use of this form, improper

transaction of the WIC check, or habitual shortages of formula may lead to termination of the store’s WIC agreement.

12. STORE REPRESENTATIVE SIGNATURE

13. TITLE

14. DATE

15. SIGNATURE OF THE CUSTOMER

16. DATE

Complete PART A of this form, make a copy, and keep the copy as store’s record. Give the original to the customer and instruct them to

return it to their local WIC office before the last day to use noted in Box 8.

PART B. PARTICIPANTS

 Take the original to the WIC office no later than the LAST DATE TO USE shown in Box 8 above.

 Your local WIC staff will provide you with a new WIC check for the remaining formula.

 If you do not give the form to your WIC office on or before the LAST DATE TO USE you will forfeit the remainder of the formula.

Do not give this form to a store. They cannot accept it as payment for formula.



PART C. LOCAL AGENCY USE ONLY

17. DATE FORM RECEIVED IN LOCAL AGENCY

18. REPLACEMENT WIC CHECK NUMBER

LOCAL AGENCY INSTRUCTIONS:

 If received on or before the LAST DATE TO USE, issue a new WIC check for the remaining cans of formula that were not redeemed

as indicated on this form. The replacement WIC check should have the same LAST DATE TO USE as the original WIC check.

 Make a copy of the completed form and mail it to the address below or fax it within 10 days. Retain the original in participant’s file.

WIC and Nutrition Services/ Missouri Department of Health and Senior Services

P.O. Box 570, Jefferson City, MO 65102-0570

Fax: 573-526-1470

• If needed, counsel the participant, guardian, or proxy on proper procedures in redeeming the entire formula WIC check

21. WIC PERSONNEL SIGNATURE

22. DATE

This institution is an equal opportunity provider.

MO 580-1596

WIC-21 (11-15)

Form Wic-21 - Partial Wic Formula Redemption Form - Wic And Nutrition Services Missouri Department Of Health And Senior Services

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