Least Expensive Brand Declaration Form Page 3

Download a blank fillable Least Expensive Brand Declaration Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Least Expensive Brand Declaration Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

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
UPC
JUICE –FLUID
C
-F
; N
J
C
List all 12 #s below product bar code
(CAT 04)
ALCIUM
ORTIFIED IS ALLOWED
O
UICE
OCKTAILS
Apple&Eve
Big Tex
Fiesta
Food Club
HEB
Hy-Top
Parade
Apple
SELECT ONE:
48
No Cider
Fluid oz.
Seneca
Shurfine
Texsun
O
- N
:
THER
AME
(indicate UPC for all items if
Albertsons
Always Save
Apple&Eve
Regular or Big Bird)
Best Choice
SELECT ONE:
(
declaring more than one
Regular:
Big Tex
Fiesta
Food Club
Great Value
Hansen’s Natural
Harvest Classic
HEB
variety for a brand, ex:
64
HyTop
Kroger
Langers
LuckyLeaf
Market Pantry
Mott’s
JuicyJuice
Old Orchard
regular or calcium fortified)
Fluid oz.
Parade
Ruby Kist
Safeway
Seneca
Shurfine
Texsun
Tipton Grove
Tree Top
w/Calcium:
O
- N
:
THER
AME
Big Tex
HEB
Parade
Shurfine
Shur Savings
Texsun
Grape (Purple)
48
SELECT ONE:
Fluid oz
O
- N
:
THER
AME
Albertsons
Best Choice
Big Tex
Food Club
Great Value
SELECT ONE:
Regular:
Hansen’s Natural
HEB
Hy-Top
Kroger
Langers
Market Pantry
Old Orchard
64
Fluid oz.
Parade
Ruby Kist
Safeway
Shurfine
Texsun
Tipton Grove
ValuTime
w/Calcium:
O
- N
:
THER
AME
48
Grape (White)
Big Tex
HEB
Parade
Texsun
SELECT ONE:
O
- N
:
THER
AME
Fluid oz.
Albertsons
Best Choice
Big Tex
Food Club
Great Value
Hansen’s Natural
SELECT ONE:
64
HEB
HyTop
Kroger
Langers
Market Pantry
Old Orchard
Parade
Ruby Kist
Fluid oz.
Safeway
Shurfine
Texsun
O
- N
:
THER
AME
Grapefruit
Pink
(indicate white, pink or red)
48 Fluid oz.
Red
White
Pink
64 Fluid oz.
Red
White
Orange
Non-refrigerated:
(for other varieties indicate
Calcium-fortified:
48 Fluid oz.
type - ex: Pulp, No or pulp
Other:
free, home-style, country
style)
Other:
(Ex: Other: Tasty OJ w/o pulp)
Non-refrigerated(NR):
NR Calcium-fortified:
NR Other:
NR Other:
64 Fluid oz.
Refrigerated:
Calcium-fortified (Refrigerated):
Refrigerated Other:
Refrigerated Other:
Orange/Mango
Big Tex
HEB
Parade
Texsun
48 Fluid oz. SELECT ONE:
O
- N
:
THER
AME
Big Tex
Parade
Texsun
64 Fluid oz. SELECT ONE:
O
- N
:
THER
AME
Orange/Pineapple
48 Fluid oz.
Pineapple/Orange
64 Fluid oz.
Or
:
Big Tex
Fiesta Mart
Food Club
HEB
HyTop
Parade
Shurfine
SELECT ONE
Pineapple
48 Fluid oz.
Texsun
O
-N
:
THER
AME
Albertsons
Best Choice
Big Tex
Fiesta
Food Club
Hansen’s Natural
HyTop
SELECT ONE:
64 Fluid oz.
Kroger
Langers
Parade
Ruby Kist
Shurfine
Texsun
O
- N
:
THER
AME
Pineapple/Mango
Big Tex
HEB
Parade
Texsun
48 Fluid oz. SELECT ONE:
O
- N
:
THER
AME
Big Tex
Parade
Texsun
64 Fluid oz. SELECT ONE:
O
- N
:
THER
AME
Big Tex
Fiesta Mart
Parade
Shurfine
Texsun
SELECT ONE:
Vegetable
48 Fluid oz.
O
- N
:
THER
AME
Regular or Low Sodium
Albertsons
Best Choice
Big Tex
Diane’s Garden
Fiesta
Food Club
SELECT ONE:
Regular:
Great Value
Hy-Top
Langers
Market Pantry
Parade
Ruby Kist
Shurfine
64 Fluid oz.
Low
Texsun
O
- N
:
THER
AME
Sodium:
Manager’s Signature:
Declaration Date:
For WIC Staff Use Only:
Verified By & Date:
Scanned By & Date:
Revised 08/01/16
Page 3 of 4

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Least Expensive Brand Declaration Form Least Expensive Brand Declaration Form Business
Form 3 - Statutory Declaration Form Form 3 - Statutory Declaration Form Financial
Form Dr 8440 - Sole Source Of Supply/brand Registration Form Form Dr 8440 - Sole Source Of Supply/brand Registration Form Financial
Expense Reimbursement Request Form Expense Reimbursement Request Form Business
Expense Reimbursement Request Form - Rts Retro-tech Systems, Inc. Expense Reimbursement Request Form - Rts Retro-tech Systems, Inc. Business
Form It-qee-sso2 - Qualified Education Expense Credit Reporting Form Form It-qee-sso2 - Qualified Education Expense Credit Reporting Form Financial
Form It-qee-tp1 - Qualified Education Expense Credit Preapproval Form Form It-qee-tp1 - Qualified Education Expense Credit Preapproval Form Financial
Form Jy0333 - Dental Expense Claim - Metlife Form Form Jy0333 - Dental Expense Claim - Metlife Form Business
Form It-qee-sso2 - Qualified Education Expense Credit Reporting Form Form It-qee-sso2 - Qualified Education Expense Credit Reporting Form Financial
Declaration Form Of Domestic Partnership Declaration Form Of Domestic Partnership Business

Related Categories

Parent category: Financial
Download
Go
Page of 4