WIC Referral Form

2023-2024 Income Guidelines

*All income is done by gross amount
Family Size	Annual	Monthly	Weekly
1	$26,973	$2,248	$519
2	$36,482	$3,041	$702
3	$45,991	$3,883	$885
4	$55,500	$4,625	$1,068

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.