Online Nevada WIC Benefit Replacement Attestation Form

This form 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

Date

Family ID(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

I attest that my WIC food benefits purchased during the current month were: (Select one)(Required)

Lost

Damaged

Destroyed

Date and description of the disaster or emergency(Required)

Describe what happened to the WIC food benefits(Required)

Upload Documents and Pictures

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 200 MB.

Submit additional documents and pictures that may be helpful to determine WIC food benefit replacement eligibility

I understand that (Select all):(Required)

Only WIC food benefits purchased in the current month may be replaced.

WIC food benefits purchased in the previous months cannot be replaced.

The information I provided is true and accurate to the best of my knowledge.

The amount of replacement benefits is determined by the Nevada WIC State Office, based on the circumstances of the loss, damage, or destruction of the food benefits, by the totality of the evidence submitted in this form, and dependent upon available WIC funding.