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  • Community Health Alliance WIC Application Form

    Please fill in the form below
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  • Household Size

  • Your household is everyone who lives in your home (including children) and shares income and household expenses (bills, food, etc.). Your household may include people who are related to you and people who are not.


    Note: If a woman in your household is pregnant and applying for WIC benefits you may then increase your household size by the number of expected births. For example, a pregnant woman, with one unborn child, would increase her household size by '1'.

     

  • Childrens's name (under 5 years of age only)

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    • Income

      Please fill out based on the income your household has received in the last 30 days.
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    • Documentation List

      You will need to attach several documents to your WIC application.
    • Proof of income examples 
    • Proof of Income Examples

      (Attach one of the following examples)

      •Recent (last 30 days) paycheck stubs or copies of paychecks (at least one month

      •Recent Income Tax Return

      •Social Security or SSI 

      •Unemployment benefit checks 

      •Proof of Child Support or Alimony (Court Letter or statement from parent. If self-reported, you may be asked to provide additional proof.)

      •Signed statement by employer

      •Signed statement of no income (with explanation)

      •Business Account Statements (if you are self-employed)

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    • Proof of Identity

    • Proof of Identity examples 
    • Proof of Identity Examples (Woman or Adult- parent, guardian)

      (Attach one of the following examples)


      •Photo Identification (Driver's License or Passport)

      •Work ID/School ID Card/Medicaid Card or letter

      •Military ID

      •Health benefits or Social Services card

      •Pay stubs

      •Voter registration

      •Tribal ID card

       

      Proof of Identity Examples (Child/Infant)

      (Attach one of the following examples)


      •Child's Birth Certificate

      •Immunization Records

      •Hospital birth record

      •Medicaid Card/Letter

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    • Proof of Residency

    • Proof of Residency examples 
    • Proof of Residency Examples

       (Attach one of the following examples)

      The following is accepted documentation of residency:

      •Current utility bills for the residence reported

      •Rent or mortgage receipts for lodging/housing

      •Statement from landlord

      •State of Nevada driver’s license or state I.D. with current physical address

      •Health benefits or Social Services letter (Medicaid, SNAP,TANF)

      •Pay Stubs

      •Voter Registration

      •Tribal ID card

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