WIC Reimbursement Form

WIC Request Form

This field is for validation purposes and should be left unchanged.
Name(Required)
Mailing Address(Required)
For which expenses are you requesting reimbursement?(Required)
Please enter the amount of the reimbursement request for the following receipts (up to 3 receipts).

Receipt

In the following section, you'll be asked to upload any qualifying receipts or payment confirmations. There is a limit of one receipt per question space, this form allows you to upload a total of 3 receipts. If you have additional receipts please either fill out an additional form, or merge receipts into one file to upload.
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
To help promote security for reimbursement funds, please include the 4 digit numerical PIN that was provided to you by MIFMA. If you are unable to remember your PIN, please enter 0000 and MIFMA will reach out for additional verification.
By checking the following box, you certify that the information provided is accurate and the expenses will support your acceptance of WIC Produce Connection EBT benefits. You also acknowledge that reimbursement is subject to approval and may require additional documentation or clarification.(Required)