<p> Replacement of Unavailable/Stolen Formula</p><p>Participant Name</p><p>WIC ID Number or eWIC Card PAN</p><p>Formula Name Number of Containers Reported as Unavailable/Stolen Number of Containers Replaced</p><p>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.</p><p>Signature of Participant or Guardian: </p><p>Date Signed:</p><p>For Agency Use Only</p><p>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</p><p>WIC Local Agency</p><p>WIC Staff Name</p><p>57-912 (3/2016)</p>