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  1. (including children over age 5, parents/sibling, significant others/spouses)
  2. Names and Date of Births
  3. INCOME: Please check all that apply
  4. Include all earnings (before tax income) in the household, including social security benefits and child support payments.
  5. Have you been on WIC before?
  6. This institution is an equal opportunity provider
  7. Leave This Blank:

  8. This field is not part of the form submission.