Louisiana Department of Health & Hospitals | Bruce Greenstein, Secretary
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WIC Vendor or Grocery Store Fraud Reporting Form
Vendor or Grocery Name:
Vendor Number:
(Only applicable if a Vendor)
Vendor or Grocery Owner Name:
(First Name)
(Last Name)
Vendor or Grocery Address:
City:
State:
Zip Code:
Vendor or Grocery Telephone Number:
(Please enter the phone number in XXX-XXX-XXXX format)
In the box below, please provide a description of the suspected WIC Vendor fraud. Be sure to include the important details such as names of persons suspected and dates if available.
Suspected Fraud:
You are able to report suspected WIC Vendor fraud anonymously, but if you would like the WIC State Agency to contact you, please complete the fields below:
Name:
Telephone Number:
E-Mail Address:
