Product Information - Illinois Department of Human Services



-457200000Illinois WIC Authorized Product List UPC Submission FormIllinois WIC Authorized Product List UPC Submission FormIf a food item is not scanning as a WIC approved item a request can be submitted to have the product reviewed. To submit a product, complete the information below or for multiple items complete the IL WIC UPC Request Spreadsheet. All submissions must be for a product that is currently approved on the Illinois WIC Authorized Food List and include photos that clearly show the Nutrition Facts, including ingredients, size, UPC, product name and brand. Submit completed forms and photos to DHS.WICFoods@. Contact InformationFirst Name _________________________________________ Last Name _________________________________Company Name (optional) _________________________________________Email Address _________________________________________ Phone Number___________________________Today’s Date ___________________________Product InformationUPC Number(12-13-digits)Brand Name of ProductFood DescriptionContainer Size (in ounces)Additional CommentsUPC Number(12-13-digits)Brand Name of ProductFood DescriptionContainer Size (in ounces)Additional CommentsProduct InformationUPC Number(12-13-digits)Brand Name of ProductFood DescriptionContainer Size (in ounces)Additional CommentsUPC Number(12-13-digits)Brand Name of ProductFood DescriptionContainer Size (in ounces)Additional Comments-57150026098400This Section to be Completed by State WIC Staff Only:? UPC Request APPROVED ? UPC Request DENIEDReason Request Denied: _____________________________________________________________________Approved By ________________________________________ Date ___________________________ ................
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