Family Information Form
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Alaska Women, Infants, Children (WIC) Program, Division of Public Assistance
Family Information Form
(one per family)
A A
r
Parent /G
d'
t
r
d
5
,pp 1cant or
uar ian or app 1cants un er age
Today's Date:
Name (First, Middle, Last)
Maiden Name
Birth Date
Mailing Address
City
AK
Zip Code
Home Phone
Cell Phone
Message Phone
May we call or leave a message?
D
yes
D
no
May we
send
a post card for appointment reminders?
D
yes
0
no
Residence address
(if different than
mailing address)
City
AK
Zip Code
Email address
What is the highest grade in school you completed?
Are you Hispanic or Latino
D
yes
D
no
Race: (You may
select
more than one race)
D
American Indian/Alaskan Native
D
Black/African American
DWhite
OAsian
D
Native Hawaiian/Pacific Islander
Would you like some one else 's name on your
checks,
who can pick up and use your checks for you?
D
yes
n
no
If
yes,
please print name:
B
Household Information
(Please
provide
proof
of
income.
Provide
proof
of identification
except
ifyou
live
in a
rnral area
with
no road
access
and
less
than
5,000 people.)
Are you currently on WIC?
D
yes
D
no
If
yes,
where?
_ _
__
__
_
Have you been on WIC before?
D
yes
D
no
If
yes,
where?
_ _ _ _ __
How
did
you
hear about WIC? -
-- - - - - - - - - - -
--
-
-- - - - -
--
-- -
Are
you
applying for your own WIC benefits today?
D
yes
D
no
Are you currently working?
D
yes
D
no
Pay
per hour?
Hours worked
_ _
per week?
Is anyone
else in the household working?
D
yes
D
no
Pay
per hour?
Hours work d
per wee
e
k?
How many people
are
living in your household?
_
How many members received
last
year's
Permanent
Check here if pregnant
D
Fund Dividend (PFD)?
(Include
PFD
even
if
garnished)
Check any
of the following programs
you
or any family member
is
currently
receiving:
D
food Stamps
D
Medicaid
D
Denali Kid Care
D
Alaska Iemporary Assistance Program
D
Heag Start
D
.S.chool Lunch Program
D
Applied for Denali Kid Care, Medicaid, ATAP-
"Application
is
oending"
Check
any
other money received:
D
Supplemental Security Income
/
Disability
D
Self Employment
D
Unemployment
D
Native Corporation Dividends
OCommissions
D
Other
Are you?
D
Married
0
Single
D
Divorced
D
Separated
D
Living with a partner/significant other
Do
you
want to register to
vote
here at the WIC office? Dyes
D
no
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