WIC Participant Complaint Form

(First)
(Last)
(if available)
(Please list names and WIC participant ID Numbers (if available))
(if available)
(Please enter the phone number in XXX-XXX-XXXX format.)

In the box below, please provide a description of the complaint against the WIC participant or caregiver. Be sure to include the important details such as names of persons involved and dates if available.

(Time Format Example: 2:00 pm)

You are able to file a WIC Participant/Caregiver complaint anonymously, but if you would like the WIC State Agency to contact you, please complete the fields below: