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Food Price List (FPL)Application Food Price List 4/16/2015 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Store nameTelephoneStore or Corporate Email AddressCounty FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Store AddressCityStateZip Code FORMTEXT ????? FORMTEXT ?????Manager nameWork Telephone FORMTEXT ????? FORMTEXT ?????Name of person completing this Price ListWork TelephoneInstructions:Enter the county in which your store resides. If already authorized enter your four digit Vendor Stamp numberCounty: FORMTEXT ?????Vendor Stamp #: FORMTEXT ?????Now save this document to your computer. Name it by the county, your four digit Vendor Stamp #, and the letter “FPL” (Example: Allen0124 FPL)Applicants, (stores not currently authorized) name by county, store name and address. (Example: Marion Save A Lot 123 Main St. Indianapolis FPL)You may encounter a message while in the process of saving the form that states there may be a minor loss of fidelity, if this occurs, click continue and save the form. 2) This Food Price List must be completed on a computer. Phone 800 522.0874 if you are unable to do this.3) Open the saved Food Price List from your computer. Complete all sections of the Food Price List for all WIC authorized foods that you routinely stock. Tab to advance through the document. Incomplete Food Price Lists cannot be processed and will be returned to the store. 4) If you have questions, explanations or comments, please enter them on the last page. 5) Save the completed Food Price List with the correct name to your computer for your record.6) Last step; e-mail the completed Food Price List AND Vendor Application to: WICVendorMail@ISDH. with 2 attachments.Minimum Inventory of WIC Approved Foods: Below is a list of the minimum quantity and varieties that must be stocked by applicants to be considered for authorization. (Refer to Vendor Food Card for approved foods. )100% Dairy Milk: 12 gallons total: 3 whole, 2 reduced fat, 7 low fat and skim milk in gallons.Cheese: 2 kinds, 3 lbs. of domestic pre-packaged, block or sliced. Must be packaged in 8 oz. or 16 oz. sizes.Eggs: 3 dozen large or extra-large white eggs in 1 dozen containers. Dry Beans, Peas or Lentils and Canned Beans: 2 kinds for a total of 3 lbs. in 1-lb. bags and 128 oz. of canned beans 15 oz. or larger.Cereal: 6 kinds of dry and 1 kind of cooked, for a total of 20 boxes. Vendor must stock at least one (1) whole grain cereal.100% Juice and minimum 120% Vitamin C: 15-64 oz. containers and 3 kinds, 5 cans of 11.5 or 12 oz. frozen juice and/or shelf stable concentrate and 2 kinds. Peanut Butter: 5 jars, 16-18 oz. Formula:6-12.1 fluid oz. container Gerber Good Start Gentle concentrate20-12.7 oz. container Gerber Good Start Gentle powder5-12.4 oz. container Gerber Good Start Soothe powder5-12.9 oz. container Gerber Good Start Soy powderInfant Cereal: 8 boxes and 2 kinds of 8 oz. dry cereal, without fruit.Baby food: 48-4 oz. jars of baby food fruits or vegetables. 16-2.5 oz. glass jars of baby food meat.Bread: 5 loaves of WIC approved whole grain bread in 16 oz. packages.Fruits and Vegetables: $30 worth of fresh fruits or vegetables, two varieties of each. Organic fruits and vegetables are approved.Does your store have all of the required WIC food listed above on hand? FORMCHECKBOX Yes FORMCHECKBOX NoMILK: Least expensive brand only. No organic.PriceWhole FORMTEXT ????? FILLIN \* MERGEFORMAT gal.2% Reduced fat FORMTEXT ?????gal.?% or 1% Low fat FORMTEXT ?????gal.Skim FORMTEXT ?????gal.Whole FORMTEXT ?????? gal2% Reduced fat FORMTEXT ?????? gal?% or 1% Low fat FORMTEXT ?????? galSkim FORMTEXT ?????? galPriceLactose Reduced/Free FORMTEXT ????? FILLIN \* MERGEFORMAT ? galLactose Reduced/Free FORMTEXT ?????quartSilk Soy Milk Original FORMTEXT ?????? gal.8th Continent Soy Milk FORMTEXT ?????? gal.Evaporated FORMTEXT ?????12 oz.Powdered FORMTEXT ?????9.6 oz.Powdered FORMTEXT ?????25.6 oz.UHT FORMTEXT ?????quart CHEESE: Highest price. May be block, sliced or shredded. No organic. 8 oz. 16 oz.American FORMTEXT ????? FILLIN \* MERGEFORMAT FORMTEXT ?????Cheddar FORMTEXT ????? FORMTEXT ?????Colby FORMTEXT ????? FORMTEXT ?????Colby-Jack FORMTEXT ????? FORMTEXT ?????Mozzarella FORMTEXT ????? FORMTEXT ?????Monterey-Jack FORMTEXT ????? FORMTEXT ?????Provolone FORMTEXT ????? FORMTEXT ?????Swiss FORMTEXT ????? FORMTEXT ?????Blend FORMTEXT ????? FORMTEXT ?????YOGURT: 32 oz. (quart) plain or flavored. No: Greek yogurt or light varieties with artificial sweeteners. 40 g. of sugar per cup is maximum. No organic. PriceBrandNonfat or Low fat FORMTEXT ????? FORMTEXT ?????Nonfat or Low fat FORMTEXT ????? FORMTEXT ?????Whole fat FORMTEXT ????? FORMTEXT ?????Whole fat FORMTEXT ????? FORMTEXT ?????EGGS DOZEN: Least expensive brand only. No organic.PriceRegular Extra Large White FORMTEXT ?????Regular Large White FORMTEXT ????? CANNED BEANS: Highest priced variety. No organic.PriceBlack FORMTEXT ?????15-16 oz.Garbanzo FORMTEXT ?????15-16 oz.Great Northern FORMTEXT ?????15-16 oz.Kidney FORMTEXT ?????15-16 oz.Navy FORMTEXT ?????15-16 oz.Pinto FORMTEXT ?????15-16 oz.Lima FORMTEXT ?????15-16 oz.Fat free refried FORMTEXT ?????15-16 oz.Black-eye peas FORMTEXT ?????15-16 oz.DRY BEANS, PEAS AND LENTILS: 1 lb. (16 oz.) bags. No organic.Price FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FISH: Packed in water, oil or vegetable broth. Highest priced variety. No organic.Chunk Light Tuna:Pink Salmon: FORMTEXT ?????5 oz. FORMTEXT ?????5 oz. FORMTEXT ?????12 oz. FORMTEXT ?????6 oz. FORMTEXT ?????7.5 oz. FORMTEXT ?????14.75 oz.REGULAR PEANUT BUTTER: 16-18 oz. jars only. Smooth or crunchy, no spreads. No organic. PriceStore brand FORMTEXT ?????Other FORMTEXT ?????Highest price FORMTEXT ?????GRAINS: approved bread whole grain/wheat 16 oz. loaves. No organic.16 oz. Bread:PriceAunt Millie’s: FORMTEXT ?????Best Choice: FORMTEXT ?????Bunny: FORMTEXT ?????Butternut: FORMTEXT ?????Family Choice: FORMTEXT ?????Healthy Life: FORMTEXT ?????Holsum: FORMTEXT ?????Kroger: FORMTEXT ?????Meijer: FORMTEXT ?????Nature’s Own: FORMTEXT ?????Roman Meal: FORMTEXT ?????Sara Lee: Classic FORMTEXT ?????Schnuck’s: FORMTEXT ?????Schwebel: FORMTEXT ?????Spartan: FORMTEXT ?????Sunbeam: FORMTEXT ?????Village Hearth: FORMTEXT ?????Wonder: FORMTEXT ?????16 oz. Tortilla: No OrganicPriceBest Choice: Whole Wheat FORMTEXT ?????Best Choice: Corn FORMTEXT ?????Carlita: Corn FORMTEXT ?????Carlita: Whole Wheat Whole Grain FORMTEXT ?????Chi-Chi’s: Whole Wheat FORMTEXT ?????Chi-Chi’s: Corn FORMTEXT ?????Don Pancho: Whole Wheat FORMTEXT ?????Don Pancho: Corn FORMTEXT ?????Food Club: Whole Wheat FORMTEXT ?????Guerrero: Whole Wheat FORMTEXT ?????Guerrero: Corn FORMTEXT ?????Kroger: Whole Wheat FORMTEXT ?????La Banderita: Whole Wheat FORMTEXT ?????La Banderita: Corn FORMTEXT ?????La Burrita: Corn FORMTEXT ?????Meijer: Whole Wheat 8” Fajita Size FORMTEXT ?????Mission: Whole Wheat FORMTEXT ?????Mission: Corn FORMTEXT ?????Ortega: Whole Wheat FORMTEXT ?????Schnucks: Whole Wheat FORMTEXT ?????Shurfresh: Corn/Maiz Tortillas 6” FORMTEXT ?????Spartan: Whole Wheat 8” Fajita Style FORMTEXT ?????Brown Rice:14-16 oz. No organic.PriceBrown Rice FORMTEXT ?????Brown Rice FORMTEXT ?????Whole Wheat Pasta: 16 oz. No organic.PriceWhole Wheat Pasta FORMTEXT ?????Whole Wheat Pasta FORMTEXT ?????CEREAL: 18 oz. minimum size. List the price of all the approved cereals that you stock. *Indicated a minimum of 51% whole grain cereal. Vendors must stock at least one whole grain cereal. General Mills:PriceSizePriceSize*Cheerios ? Regular FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Multi Grain Cheerios FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.Corn Chex FORMTEXT ?????18 oz.Rice Chex FORMTEXT ?????18 oz.*Kix ? (regular) FORMTEXT ?????18 oz.Dora the Explorer ? (regular) FORMTEXT ?????18 oz.Kellogg’s:PriceSizePriceSizeCrispix ? FORMTEXT ?????18 oz.Corn Flakes ? FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Frosted Mini Wheats ? Big Bite FORMTEXT ?????18 oz.*Frosted Mini Wheats ? Original FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Mini Wheats ? Unfrosted FORMTEXT ?????18 oz.*Scooby-Doo ? FORMTEXT ?????18 oz.*All-Bran? Wheat Flakes FORMTEXT ?????18 oz.Rice Krispies? (regular) FORMTEXT ?????18 oz.*Special K ? (original) FORMTEXT ?????18 oz.Post?:PriceSizePriceSize*Grape Nut ? Flakes FORMTEXT ?????18 oz.Honey Bunches of Oats?:Honey Roasted FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Vanilla Bunches FORMTEXT ?????18 oz.Banana Blueberry FORMTEXT ?????18 oz.Almonds FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.Cinnamon Bunches FORMTEXT ?????18 oz.Malt-O-Meal:PriceSizePriceSize*Frosted Mini Spooners? FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Strawberry Cream Mini Spooners? FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Blueberry Mini Spooners? FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.Oat Blenders? Honey FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.Crispy Rice? FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.Quaker?:PriceSize*Life? FORMTEXT ?????18 oz.HOT CEREALS:PriceSizePriceSizeMalt-O-Meal? FORMTEXT ?????18 oz. FORMTEXT ?????36 oz.*Cream of Wheat? Whole Grain FORMTEXT ?????18 oz.*Quaker Instant Oatmeal Original FORMTEXT ?????11.8 oz.JUICE: 64 oz. containers only. All juice categories must be 100% juice and a minimum of 120% vitamin C. List brands and price for each category. No organic.Shelf Stable 64 oz. Juice:Orange Juice 64 oz.:BrandPrice FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Apple Juice 64 oz.: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grape Juice 64 oz. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grapefruit Juice 64 oz.: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Pineapple Juice 64 oz.: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tomato and Vegetable Juice 64 oz.: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Juices 64 oz.:Juicy Juice, any flavor FORMTEXT ?????Old Orchard 100% Juice FORMTEXT ?????Refrigerated 64 oz. Juice:Orange Juice 64 oz.:BrandPrice FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grapefruit Juice 64 oz.: FORMTEXT ????? FORMTEXT ?????JUICE CONCENTRATES: Frozen only. No organic.Frozen 11.5-12 oz. Juice:Orange Juice:BrandPrice FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grapefruit Juice: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Apple Juice: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grape Juice: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other:Welch’s any flavor with yellow tab FORMTEXT ?????Old Orchard any flavor with green tab FORMTEXT ?????Dole 100% Juice(any flavor) FORMTEXT ?????Shelf Stable ConcentrateWelch’s 100% Juice (any flavor) FORMTEXT ?????INFANT CEREAL: 8 oz. any grain or multi-grain. (except Quinoa). No organic.BrandPrice FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????BABY FOOD: No organic.4 oz. Fruits & VegetablesBrandPrice FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2.5 oz. Meat, may include broth or gravy: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????INFANT FORMULA:Is your store also a pharmacy? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, pharmacies must provide prices for all formulas listed on this page and the next page or this application will not be processed. If your store does not have a pharmacy, then provide prices of the formulas you regularly stock.Can you obtain any of the items on the WIC formulary list page 1-3 located at within 2 working days? FORMCHECKBOX Yes FORMCHECKBOX NoWho is the WIC contact for special order formula at your store?Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????List PER CAN prices except where multiple units are indicated. NOTE: *Bolded items are required to be in stock in stores. Powder Size as SpecifiedReady to FeedLiquid ConcentrateSize PriceSize PriceSize PriceGerber Good Start Gentle*12.7 oz. FORMTEXT ?????8.45 oz. 4 pk. FORMTEXT ?????*12.1 oz. FORMTEXT ?????Gerber Good Start Soothe*12.4 oz. FORMTEXT ?????Gerber Good Start Soy*12.9 oz. FORMTEXT ?????8.45 oz. 4 pk. FORMTEXT ?????12.1 oz. FORMTEXT ?????PRESCRIPTION FORMULAReminder: Stores with pharmacies must list prices for all formulas on this page. List per can prices except where 4 pack, 6 pack, 24 per case or 48 per case is indicated. Powder Size as SpecifiedReady to FeedLiquid ConcentrateCaseSize PriceSize PriceSize PriceSize PriceBoost (any flavor)8 oz. 6 pack FORMTEXT ?????Boost Kid Essentials 1.0 cal. (any flavor)8.25 oz. 4 pack FORMTEXT ?????EleCare for Infants w/DHA& ARA14.1 oz. FORMTEXT ?????Enfamil Nutramigen w/Enflora12.6 oz. FORMTEXT ?????Enfamil Nutramigenquart FORMTEXT ????? 13 oz. FORMTEXT ?????Enfamil EnfaCare12.8 oz. FORMTEXT ?????quart FORMTEXT ?????*2 oz. /48/case FORMTEXT ????? Ensure8 oz. 6 pack FORMTEXT ?????Neocate Infant w/DHA&ARA14.1 oz. FORMTEXT ?????Neocate Junior14.1 oz. FORMTEXT ?????Pediasure (any flavor)8 oz. 6 pack FORMTEXT ?????Pediasure w/Fiber (any flavor)8 oz. 6 pack FORMTEXT ?????Pediasure 1.5 cal (any flavor)8 oz. can/24/case FORMTEXT ?????Pediasure Peptide 1.0 cal (any flavor)8 oz. can/24/case FORMTEXT ?????Similac Expert Care Alimentum16 oz. FORMTEXT ?????quart FORMTEXT ?????Similac Expert Care NeoSure13.1 oz. FORMTEXT ?????quart FORMTEXT ?????*This is not a complete list of all prescription formulas. It includes the most commonly prescribed WIC formulas. We recommend that large stores stock as many as possible. See complete list at . The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all programs and/or employment activities.)?If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@.Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).USDA is an equal opportunity provider and employer.Explanations and comments: FORMTEXT ????? ................
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