Least Expensive Brand Declaration Form
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4LEAST EXPENSIVE BRAND DECLARATION FORM
All vendors shall declare the traditionally least expensive brand for the food types listed on this form. Each WIC vendor account
outlet must complete a separate form if the traditionally least expensive brand for a particular food type is different at each outlet.
INSTRUCTIONS: Please type; or legibly print all information provided below in ink
1.
Account Name: This should match the name indicated on Line 1 of the Vendor Agreement and Line 1 of current Vendor Profile Application–Account Page.
2.
WIC Account #: List designated WIC Account Number.
3.
Outlet(s) #: List designated WIC Outlet Number.
a.
List all outlet numbers covered by this LEB Declaration form.
4.
Brand Name: List the Outlet's least expensive brand.
a.
Only one brand can be declared for each food item.
b.
Food declared must be a WIC Approved Brand.
5.
UPC (Uniform Product Code): List ALL the numbers located below and to the side of the product bar code.
6.
Each page of this form must be signed and dated by a store official.
7.
Labeling: For every item declared on this form, an authorized “WIC Approved Item” tag/label must be affixed to the shelf.
A
N
:
WIC A
#:
WIC Outlet(s)#:
CCOUNT
AME
CCOUNT
Outlet numbers must be listed below when identifying more than 1 outlet. If more space is needed, please attach a Word document.
Vendors authorized in the WIC Program must declare the traditionally least expensive brand (LEB) of each type and size of WIC authorized milk, juice,
cheese, grains and beans/peas/lentils (Policy WV: 02.0) at the time of contracting.
FOOD TYPE
SIZE
BRAND NAME
UPC
MILK (Cat 01)
N
O
, C
-F
, H
-P
F
M
List all 12 #s below product bar code
O
RGANIC
ALCIUM
ORTIFIED
IGH
ROTEIN OR
LAVORED
ILK
Gallon
Half
Low Fat -1%
Gallon
Quart
Gallon
Half
Low Fat- 0.5%
Gallon
Quart
Gallon
Half
Fat Free/Skim
Gallon
Quart
Half
Low Fat-1-½%
Gallon
Buttermilk
Half
Fat-Free/Skim
Gallon
MILK (Cat 51)
N
O
, C
-F
, H
-P
F
M
List all 12 #s below product bar code
O
RGANIC
ALCIUM
ORTIFIED
IGH
ROTEIN OR
LAVORED
ILK
Gallon
Whole
Half
Gallon
Quart
Manager’s Signature:
Declaration Date:
Verified By & Date:
Scanned By & Date:_______________________
For WIC Staff Use Only:
___________________________________________
Revised 08/01/16
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