Tip for State-specific

WIC is for pregnant women, postpartum women (up to 6 months, or 1 year if breastfeeding), and children under 5

Tip for State-specific

Income limit is generally 185% of the federal poverty level — but if you receive Medicaid, SNAP, or TANF, you automatically qualify

Tip for State-specific

WIC provides specific nutritious foods: milk, eggs, whole grains, fruits, vegetables, infant formula

Maternal & Pediatricmoderate

WIC Application

State-specific · USDA Food and Nutrition Service (state-administered)

Application for WIC nutrition assistance providing education, breastfeeding support, and benefits for healthy foods. Requires proof of identity, address, income (or Medicaid/SNAP/TANF participation), and a health screening.

Form Details

Total fields: 55
Auto-fillable: 35 (64%)
Time without BeneFill: 45 minutes
Time with BeneFill: 12 minutes
Time saved: 33 minutes
Filled by: patient
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Contact your state or local WIC agency

https://www.fns.usda.gov/wic/toll-free-numbers-wic-state-agencies

Find your local WIC office through the USDA directory. Some states allow online pre-screening.

🏢

At your local WIC clinic (in-person visit required for certification)

An in-person nutrition assessment is typically required.

Required Attachments

📎 Proof of identity (photo ID, birth certificate for child)
📎 Proof of residency in the state (utility bill, lease)
📎 Proof of income for all household members (pay stubs, tax return, benefit award letters)
📎 Proof of pregnancy or postpartum status (if applying for mother)
📎 Immunization records for children

Processing Time

Usually same-day certification at your appointment. Benefits are typically available within 1-2 days.

What Happens Next

You will receive a WIC EBT card loaded with benefits for approved food items. You will also receive nutrition counseling and breastfeeding support if applicable.

Tips for This Form

✓ WIC is for pregnant women, postpartum women (up to 6 months, or 1 year if breastfeeding), and children under 5
✓ Income limit is generally 185% of the federal poverty level — but if you receive Medicaid, SNAP, or TANF, you automatically qualify
✓ WIC provides specific nutritious foods: milk, eggs, whole grains, fruits, vegetables, infant formula
✓ You must recertify periodically — typically every 6 months for pregnant women and annually for children

More Maternal & Pediatric Forms

WIC Medical Documentation / Nutrition Risk Form

State-specific · State WIC agencies

Medical documentation of nutrition risk factors qualifying an individual for WIC, such as anemia, underweight, or high-risk pregnancy.

CHIP Application

State-specific / Healthcare.gov · State CHIP agencies

Application for Children's Health Insurance Program for families with income too high for Medicaid but too low for private coverage. Uses MAGI-based financial eligibility. Children must be uninsured.

School Entrance Health Form

State-specific (e.g., VA MCH213G) · State Departments of Health/Education

Required for school entry. Includes immunization records, health history, physical examination, and developmental screening. Must be completed no earlier than one year before school entry.

Immunization Record / Certificate of Immunization

State-specific · State Departments of Health

Official record of required childhood vaccinations for school enrollment. Exemption forms (medical, religious, philosophical) vary by state.

Medication Administration Authorization (School)

District-specific · School districts

Authorization for school nurse or designee to administer prescribed medication during school hours.

Section 504 Plan (Medical)

District-specific · School districts

Accommodation plan for students with health conditions (diabetes, allergies, asthma, ADHD) that impact school participation. Includes a medical management plan and emergency action plan.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the USDA Food and Nutrition Service (state-administered) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.