WIC Referral Form

2024-2025 Income Guidelines

*All income is done by gross amount
Family Size	Annual	Monthly	Weekly
1	$27,861	$2,322	$536
2	$37,814	$3,152	$728
3	$47,767	$3,981	$919
4	$57,720	$4,810	$1,110
5	$67,673	$5,640	$1,302
6	$77,626	$6,469	$1,493
7	$87,579	$7,299	$1,685
8	$97,532	$8,128	$1,876
Additional Family Members Add:	+$9,953	+$830	+$192

A pregnant woman is considered to be a family of 2.

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Date of Birth

Due Date (If Known)

Do you receive Medicaid?

Do you receive SNAP?

Are you currently pregnant?

Do you have children under 5 years old in the household?

Do you meet our income guidelines?

If you answered yes to these questions, then you are eligible for the program.