Least Expensive Brand Declaration Form Page 4

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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
UPC
JUICE–FROZEN
C
-F
; N
J
C
List all 12 #s below product bar code
(CAT 04)
ALCIUM
ORTIFIED IS ALLOWED
O
UICE
OCKTAILS
Apple
Albertsons
Always Save
Best Choice
Fiesta
Food Club
Great Value
SELECT ONE:
Regular:
12 oz
Hill Co Fare
Hy-Top
Kroger
Langers
Market Pantry
Old Orchard
Parade
(no cider)
Frozen
Safeway
Seneca
ShurFine
Tree Top
O
- N
:
w/Calcium:
(indicate UPC for all items if declaring
THER
AME
more than one variety for a brand,
ex: regular or calcium fortified)
Parade
16 oz Frozen SELECT ONE:
O
- N
:
THER
AME
Grape (Purple)
:
Albertsons
Food Club
Great Value
Hill Co Fare
Hy-Top
SELECT ONE
11.5
12 oz.
or
Kroger
Langers
Old Orchard
Parade
Seneca
Welch’s
Frozen
O
- N
:
THER
AME
Grape (White)
Hill Co Fare
Langers
Old Orchard
Welch’s
11.5
12 oz.
SELECT ONE:
or
Frozen
O
- N
:
THER
AME
12 oz
Grapefruit
Frozen
Orange
Regular:
(for other varieties
indicate type - ex: Pulp,
w/Calcium:
No or pulp free, country
style)
12 oz
Other:
Frozen
(Ex: Other: Tasty OJ w/o pulp)
Other:
Other:
16 oz
Frozen
LEGUMES/DRIED BEANS
List all 12#s below product bar code
(CAT 06)
Black Beans
16 oz.
Package
Lentils
16 oz.
Package
Navy Beans
16 oz.
Package
Pinto Beans
16 oz.
Package
Split Peas
16 oz.
(Green)
Package
GRAINS - (Cat 16)
(W
W
B
, T
& R
)
HOLE
HEAT
READ
ORTILLAS
ICE
WHOLE WHEAT/GRAIN BREAD
N
B
R
. N
S
-
List all 12#s below product bar code
O
UNS AND
OLLS
O
UGAR
FREE
Best Choice
Bimbo
Great Value
HEB Bake Shop
Kroger
Mrs. Baird’s
SELECT ONE:
Whole Wheat–
16 oz.
Nature’s Own 100%
Ozark Hearth
Parade
Roman Meal
Sara Lee (Classic)
Wonder
100%
Loaf
O
-N
:
THER
AME
TORTILLAS
N
W
F
T
List all 12#s below product bar code
O
HITE
LOUR OR
OSTADAS
Soft Corn -
Best Choice
HEB
La Burrita
Mission
Porras Prontito
:
SELECT ONE
16 oz.
Yellow
Ramirez & Son
Santa Fe
Pkg
O
-N
:
THER
AME
Barron Superette
Brookshires
Don Pancho
El Lago
Guerrero
SELECT ONE:
Soft Corn –
16 oz.
La Banderita
La Campera
La Primera
Porras Prontito
White
Pkg
Santa Fe
Valle Grande
O
- N
:
THER
AME
Shelf:
Barron’s Superette
Best Choice
Don Pancho
El Lago
Guerrero
SELECT ONE:
Whole Wheat –
16 oz.
HEB
La Banderita
Mi Casa
Mission
Native
Porras Prontito
Santa Fe
100%
Pkg
O
- N
:
Refrig:
THER
AME
REF = REFRIGERATED
RICE
N
W
R
; N
A
S
, A
S
, F
, O
S
O
HITE
ICE
O
DDITIVES OR
EASONINGS
DDED
UGAR
AT
IL OR
ALT
Adolphus
Albertsons
Best Choice
Blue Ribbon
C&F
Food Club
SELECT ONE:
Great Value
Gulf Pacific
HEB
Hinode
HyTop
Kroger
Mahatma
16 oz.
Brown Rice
Pkg
Market Pantry
Parade
Peak
Riceland
Safeway
Shurfine
Springfield
O
-N
:
THER
AME
Manager’s Signature:
Declaration Date:
Verified By & Date:
Scanned By & Date:
For WIC Staff Use Only:
Revised 08/01/16
Page 4 of 4

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