The fillable form below is used to document a participant’s attestation that WIC Food Benefits purchased during the current month were lost, damaged, or destroyed as a direct result of a disaster or emergency. The participant must complete and sign the form.
The completed and signed form must be sent to WICGeneral@health.nv.gov. In the email, include additional documents and pictures that may be helpful to determine food benefit replacement eligibility. Please click on the link below to complete the form.