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Women, Infants, and Children (WIC) Application

  1. WIC Application Form
    Only Sherburne County residents may apply. For residents of other Minnesota counties, please call 1-800-942-4030.

    Contact WIC at 763-765-4116 or 800-433-5239 with any questions about your application
  2. People in the same household are related or non-related and share in consumption of the same goods and services. If you are applying for your foster children, each foster child is considered family of one. Pregnant women count as two.
    Include any children that you are paying child support for.
  3. Please list any household members who are pregnant or postpartum women and children under 5.
  4. Please check all services that the household receives:
  5. Financial Information: Please report gross income (before taxes)
    (Annual income based on federal tax forms: Form 1040 - line 22, Form 1040A - line 15, Form 1040EZ - line 6)
  6. If no income, put 0
  7. Certification*
    I certify that the information I have provided is correct to the best of my knowledge. I understand that intentionally giving false or misleading information will result in my not receiving WIC benefits.
  8. Leave This Blank:

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