Least Expensive Brand Declaration Form Page 2

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LEAST EXPENSIVE BRAND DECLARATION FORM - Continued
A
N
:
WIC A
#:
WIC Outlet(s)#:
CCOUNT
AME
CCOUNT
ALL OUTLETS
If more than one Outlet is covered by this Declaration Form, List the Numbers below:
FOOD TYPE
SIZE
BRAND NAME & TYPE
UPC
CHEESE
N
I
W
S
S
C
. N
P
C
F
/P
V
®. N
C
D
.
(Cat 02)
O
NDIVIDUALLY
RAPPED
LICES OR
HREDDED
HEESE
O
ROCESSED
HEESE
OOD
RODUCT OR
ELVEETA
O
HEESE FROM THE
ELI
List all 12 #s below product bar code
L
T
: B
S
L
/R
F
(E
: (M
C
) K
– B
– R
F
)
IST THE
YPE
LOCK OR
LICED AND
OW
EDUCED
AT
XAMPLE
ILD
HEDDAR
RAFT
LOCK
EDUCED
AT
1-lb.
White
Package
(indicate type: i.e, Block or
2-lb.
Sliced and Low/Reduced Fat)
Package
1-lb.
Yellow
Package
(indicate type: i.e, Block or
2-lb.
Sliced and Low/Reduced Fat)
Package
1-lb.
Package
Mild
(indicate type: i.e, Block or
Sliced and Low/Reduced Fat)
2-lb.
Package
1-lb.
Package
Medium
(indicate type: i.e, Block or
Sliced and Low/Reduced Fat)
2-lb.
Package
1-lb.
Package
Sharp
(indicate type: i.e, Block or
2-lb.
Sliced and Low/Reduced Fat)
Package
Extra Sharp
1-lb or 2lb.
Package
(indicate size & if Low/Reduced Fat)
1-lb.
Package
Longhorn Style
(indicate type: i.e, Block or
Sliced and Low/Reduced Fat)
2-lb.
Package
1-lb.
Colby
Package
(indicate type: i.e, Block or
2-lb.
Sliced and Low/Reduced Fat)
Package
1-lb.
Package
Colby-Jack
(indicate type: i.e, Block or
Sliced and Low/Reduced Fat)
2-lb.
Package
1-lb.
Package
Monterrey Jack
2-lb.
Package
(Indicate type: i.
Sliced and Low/Reduced Fat)
1 or 2-lb.
Pkg
1-lb.
Package
Mozzarella
2-lb.
Package
String Cheese
1 lb.
P
Manager’s Signature:
Declaration Date:
Verified By & Date:
Scanned By & Date:
For WIC Staff Use Only:
Revised 08/01/16
Page 2 of 4

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