Food Price List (FPL) Application Food Price List 4/16/2015

Store name Telephone Store or Corporate Email Address County

Store Address City State Zip Code

Manager name Work Telephone

Name of person completing this Price List Work Telephone

Instructions:

1) Enter the county in which your store resides. If already authorized enter your four digit Vendor Stamp number

County: Vendor Stamp #: Now save this document to your computer. Name it by the county, your four digit Vendor Stamp #, and the letter “FPL” (Example: Allen0124 FPL)

Applicants, (stores not currently authorized) name by county, store name and address. (Example: Marion Save A Lot 123 Main St. Indianapolis FPL)

You may encounter a message while in the process of saving the form that states there may be a minor loss of fidelity, if this occurs, click continue and save the form.

2) This Food Price List must be completed on a computer. Phone 800 522.0874 if you are unable to do this.

3) Open the saved Food Price List from your computer. Complete all sections of the Food Price List for all WIC authorized foods that you routinely stock. Tab to advance through the document. Incomplete Food Price Lists cannot be processed and will be returned to the store.

4) If you have questions, explanations or comments, please enter them on the last page.

5) Save the completed Food Price List with the correct name to your computer for your record.

6) Last step; e-mail the completed Food Price List AND Vendor Application to: [email protected] with 2 attachments.

Minimum Inventory of WIC Approved Foods: Below is a list of the minimum quantity and varieties that must be stocked by applicants to be considered for authorization. (Refer to Vendor Food Card for approved foods. https://www.in.gov/isdh/24780.htm )

1 100% Dairy Milk: 12 gallons total: 3 whole, 2 reduced fat, 7 low fat and skim milk in gallons. Formula: Cheese: 2 kinds, 3 lbs. of domestic pre-packaged, block or sliced. Must be packaged in 8 oz. or 6-12.1 fluid oz. container Gerber Good Start Gentle concentrate 16 oz. sizes. 20-12.7 oz. container Gerber Good Start Gentle powder Eggs: 3 dozen large or extra-large white eggs in 1 dozen containers. 5-12.4 oz. container Gerber Good Start Soothe powder Dry Beans, Peas or Lentils and Canned Beans: 2 kinds for a total of 3 lbs. in 1-lb. bags and 5-12.9 oz. container Gerber Good Start Soy powder 128 oz. of canned beans 15 oz. or larger. Cereal: 6 kinds of dry and 1 kind of cooked, for a total of 20 boxes. Vendor must stock at least Infant Cereal: 8 boxes and 2 kinds of 8 oz. dry cereal, without fruit. one (1) whole grain cereal. Baby food: 48-4 oz. jars of baby food fruits or vegetables. 16-2.5 oz. glass jars 100% Juice and minimum 120% Vitamin C: 15-64 oz. containers and 3 kinds, 5 cans of 11.5 of baby food meat. or 12 oz. frozen juice and/or shelf stable concentrate and 2 kinds. Bread: 5 loaves of WIC approved whole grain bread in 16 oz. packages. Peanut Butter: 5 jars, 16-18 oz. Fruits and Vegetables: $30 worth of fresh fruits or vegetables, two varieties of each. Organic fruits and vegetables are approved. Does your store have all of the required WIC food listed above on hand? Yes No

Silk Soy Milk Original ½ gal. 8th Continent Soy Milk ½ gal. Evaporated 12 oz. Powdered 9.6 oz. Powdered 25.6 oz. UHT quart

A. MILK: Least expensive brand only. No organic. B. CHEESE: Highest price. May be block, sliced or shredded. Price No organic. Whole gal. 2% Reduced fat gal. 8 oz. 16 oz. ½% or 1% Low fat gal. American Skim gal. Cheddar Whole ½ gal Colby 2% Reduced fat ½ gal Colby-Jack ½% or 1% Low fat ½ gal Mozzarella Skim ½ gal Monterey-Jack Provolone Swiss Blend

Price Lactose Reduced/Free ½ gal Lactose Reduced/Free quart

2 C. YOGURT: 32 oz. (quart) plain or flavored. No: Greek yogurt Price or light varieties with artificial sweeteners. 40 g. of sugar per cup is maximum. No organic.

G. FISH: Packed in water, oil or vegetable broth. Highest priced Price Brand variety. No organic. Nonfat or Low fat Nonfat or Low fat Chunk Light Tuna: Pink Salmon: Whole fat 5 oz. 5 oz. Whole fat 12 oz. 6 oz. 7.5 oz. D. EGGS DOZEN: Least expensive brand only. No organic. 14.75 oz.

Price Regular Extra Large White H. REGULAR PEANUT BUTTER: 16-18 oz. jars only. Smooth Regular Large White or crunchy, no spreads. No organic. Price E. CANNED BEANS: Highest priced variety. No organic. Store brand Other Highest price

Price Black 15-16 oz. I. GRAINS: approved bread whole grain/wheat 16 oz. loaves. Garbanzo 15-16 oz. No organic. Great Northern 15-16 oz. Kidney 15-16 oz. 16 oz. Bread: Price Navy 15-16 oz. Aunt Millie’s: Pinto 15-16 oz. Best Choice: Lima 15-16 oz. Bunny: Fat free refried 15-16 oz. Butternut: Black-eye peas 15-16 oz. Family Choice: Healthy Life: Holsum: F. DRY BEANS, PEAS AND LENTILS: 1 lb. (16 oz.) bags. Kroger: No organic. Meijer:

3 Nature’s Own: Brown Rice:14-16 oz. No organic. Roman Meal: Price Sara Lee: Classic Brown Rice Schnuck’s: Brown Rice Schwebel: Spartan: Sunbeam: Whole Wheat Pasta: 16 oz. No organic. Village Hearth: Price Wonder: Whole Wheat Pasta 16 oz. Tortilla: No Organic Price Whole Wheat Pasta Best Choice: Whole Wheat Best Choice: Corn Carlita: Corn Carlita: Whole Wheat Whole Grain Chi-Chi’s: Whole Wheat Chi-Chi’s: Corn Don Pancho: Whole Wheat Don Pancho: Corn Food Club: Whole Wheat Guerrero: Whole Wheat Guerrero: Corn Kroger: Whole Wheat La Banderita: Whole Wheat La Banderita: Corn La Burrita: Corn Meijer: Whole Wheat 8” Fajita Size Mission: Whole Wheat Mission: Corn Ortega: Whole Wheat Schnucks: Whole Wheat Shurfresh: Corn/Maiz Tortillas 6” Spartan: Whole Wheat 8” Fajita Style

4 J. CEREAL: 18 oz. minimum size. List the price of all the approved cereals that you stock. *Indicated a minimum of 51% whole grain cereal. Vendors must stock at least one whole grain cereal.

General Mills: Price Size Price Size *Cheerios ® Regular 18 oz. 36 oz. *Multi Grain Cheerios 18 oz. 36 oz. Malt-O-Meal: Price Size Price Size Corn Chex 18 oz. *Frosted Mini Spooners® 18 oz. 36 oz. Rice Chex 18 oz. *Strawberry Cream Mini Spooners® 18 oz. 36 oz. *Kix ® (regular) 18 oz. *Blueberry Mini Spooners® 18 oz. 36 oz. Dora the Explorer ® (regular) 18 oz. Oat Blenders® Honey 18 oz. 36 oz. Crispy Rice® 18 oz. 36 oz.

Kellogg’s: Price Size Price Size Crispix ® 18 oz. Quaker®: Price Size Corn Flakes ® 18 oz. 36 oz. *Life® 18 oz. *Frosted Mini Wheats ® Big Bite 18 oz. *Frosted Mini Wheats ® Original 18 oz. 36 oz. HOT CEREALS: Price Size Price Size *Mini Wheats ® Unfrosted 18 oz. Malt-O-Meal® 18 oz. 36 oz. *Scooby-Doo ® 18 oz. *Cream of Wheat® Whole Grain 18 oz. *All-Bran® Wheat Flakes 18 oz. *Quaker Instant Oatmeal Original 11.8 oz. Rice Krispies® (regular) 18 oz. *Special K ® (original) 18 oz.

Post®: Price Size Price Size *Grape Nut ® Flakes 18 oz. Honey Bunches of Oats®: Honey Roasted 18 oz. 36 oz. *Vanilla Bunches 18 oz. Banana Blueberry 18 oz. Almonds 18 oz. 36 oz. Cinnamon Bunches 18 oz.

5 K. JUICE: 64 oz. containers only. All juice categories must be L. JUICE CONCENTRATES: Frozen only. No organic. 100% juice and a minimum of 120% vitamin C. List brands Frozen 11.5-12 oz. Juice: and price for each category. No organic.

Shelf Stable 64 oz. Juice: Orange Juice: Brand Price

Orange Juice 64 oz.: Brand Price Grapefruit Juice:

Apple Juice 64 oz.: Apple Juice:

Grape Juice 64 oz. Grape Juice:

Grapefruit Juice 64 oz.: Other: Welch’s any flavor with Pineapple Juice 64 oz.: yellow tab Old Orchard any flavor with green tab Tomato and Vegetable Juice 64 oz.: Dole 100% Juice (any flavor)

Other Juices 64 oz.: Shelf Stable Concentrate Juicy Juice, any flavor Welch’s 100% Juice Old Orchard 100% Juice (any flavor)

Refrigerated 64 oz. Juice:

Orange Juice 64 oz.: Brand Price

Grapefruit Juice 64 oz.:

6 M. INFANT CEREAL: 8 oz. any grain or multi-grain. (except Quinoa). No organic.

Brand Price

7 N. BABY FOOD: No organic.

4 oz. Fruits & Vegetables Brand Price

2.5 oz. Meat, may include broth or gravy:

O. INFANT FORMULA:

Is your store also a pharmacy? Yes No

If yes, pharmacies must provide prices for all formulas listed on this page and the next page or this application will not be processed. If your store does not have a pharmacy, then provide prices of the formulas you regularly stock.

Can you obtain any of the items on the WIC formulary list page 1-3 located at http://www.in.gov/isdh/files/Indiana_WICFormulary.pdf within 2 working days? Yes No

Who is the WIC contact for special order formula at your store?

Name: Title: Phone: Email:

List PER CAN prices except where multiple units are indicated. NOTE: *Bolded items are required to be in stock in stores.

8 Powder Size as Specified Ready to Feed Liquid Concentrate Size Price Size Price Size Price Gerber Good Start Gentle *12.7 oz. 8.45 oz. 4 pk. *12.1 oz. Gerber Good Start Soothe *12.4 oz. Gerber Good Start Soy *12.9 oz. 8.45 oz. 4 pk. 12.1 oz.

9 P. PRESCRIPTION FORMULA

Reminder: Stores with pharmacies must list prices for all formulas on this page. List per can prices except where 4 pack, 6 pack, 24 per case or 48 per case is indicated.

Powder Size Ready to Feed Liquid Concentrate Case as Specified

Size Size Price Size Price Size Price Price

Boost (any flavor) 8 oz. 6 pack Boost Kid Essentials 1.0 cal. (any flavor) 8.25 oz. 4 pack EleCare for Infants w/DHA& ARA 14.1 oz.

Enfamil Nutramigen w/Enflora 12.6 oz.

Enfamil Nutramigen quart 13 oz. Enfamil EnfaCare 12.8 oz. quart *2 oz. /48/case

Ensure 8 oz. 6 pack Neocate Infant w/DHA&ARA 14.1 oz.

Neocate Junior 14.1 oz.

Pediasure (any flavor) 8 oz. 6 pack Pediasure w/Fiber (any flavor) 8 oz. 6 pack Pediasure 1.5 cal (any flavor) 8 oz. can/24/case Pediasure Peptide 1.0 cal (any flavor) 8 oz. can/24/case Similac Expert Care Alimentum 16 oz. quart

Similac Expert Care NeoSure 13.1 oz. quart

*This is not a complete list of all prescription formulas. It includes the most commonly prescribed WIC formulas. We recommend that large stores stock as many as possible. See complete list at http://www.in.gov/isdh/files/Indiana_WICFormulary.pdf .

10 The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected].

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).

USDA is an equal opportunity provider and employer.

Explanations and comments: