Documentation of Unavailable Or Stolen Formula - 57-912

Replacement of Unavailable/Stolen Formula

Participant Name

WIC ID Number or eWIC Card PAN

Formula Name Number of Containers Reported as Unavailable/Stolen Number of Containers Replaced

I am reporting the above formula has been stolen or cannot be safely retrieved. I understand that if the original formula is found that I must return the replacement formula to the WIC Program. If I don’t follow the rules, I may be disqualified and have to pay money back to WIC for formula I should not have received.

Signature of Participant or Guardian:

Date Signed:

For Agency Use Only

For additional information, refer to Policy 561. Send completed forms to the State WIC Office within three days. Fax: 971-673-0071 Attention: WIC Compliance Coordinator

WIC Local Agency

WIC Staff Name

57-912 (3/2016)