in.gov · Web viewLima 15-16 oz. Fat free refried 15-16 oz. Black-eye peas 15-16 oz. DRY BEANS,...
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Food Price List (FPL) Application Food Price List 4/16/2015 Store name Telephone Store or Corporate Email Address County Store Address City State Zip Code Manager name Work Telephone Name of person completing this Price List Work Telephone Instructions: 1) Enter the county in which your store resides. If already authorized enter your four digit Vendor Stamp number County: Vendor Stamp #: 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: [email protected] 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. https://www.in.gov/isdh/24780.htm ) 1
Transcript of in.gov · Web viewLima 15-16 oz. Fat free refried 15-16 oz. Black-eye peas 15-16 oz. DRY BEANS,...
Food Price List (FPL) Application Food Price List 4/16/2015
Store name Telephone Store or Corporate Email Address County
Store Address City State Zip Code
Manager name Work Telephone
Name of person completing this Price List Work Telephone
Instructions:1) Enter the county in which your store resides. If already authorized enter your four digit Vendor Stamp number
County: Vendor Stamp #: 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: [email protected] 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. https://www.in.gov/isdh/24780.htm )
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 powder
Infant 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? Yes No
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A. MILK : Least expensive brand only. No organic.
PriceWhole gal.
2% Reduced fat gal.½% or 1% Low fat gal.
Skim gal.Whole ½ gal
2% Reduced fat ½ gal½% or 1% Low fat ½ gal
Skim ½ gal
PriceLactose Reduced/Free ½ galLactose Reduced/Free quart
Silk Soy Milk Original ½ gal.8th Continent Soy Milk ½ gal.
Evaporated 12 oz.Powdered 9.6 oz.Powdered 25.6 oz.
UHT quart
B. CHEESE : Highest price. May be block, sliced or shredded. No organic.
8 oz. 16 oz.American
Cheddar Colby
Colby-Jack Mozzarella
Monterey-Jack Provolone
Swiss Blend
C. 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.
Price BrandNonfat or Low fat
Nonfat or Low fat
Whole fat
Whole fat
D. EGGS DOZEN : Least expensive brand only. No organic.
PriceRegular Extra Large White
Regular Large White
E. CANNED BEANS: Highest priced variety. No organic.
PriceBlack 15-16 oz.
Garbanzo 15-16 oz.Great Northern 15-16 oz.
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Kidney 15-16 oz.Navy 15-16 oz.Pinto 15-16 oz.Lima 15-16 oz.
Fat free refried 15-16 oz.Black-eye peas 15-16 oz.
F. DRY BEANS, PEAS AND LENTILS : 1 lb. (16 oz.) bags. No organic.
Price
G. FISH: Packed in water, oil or vegetable broth. Highest priced variety. No organic.
Chunk Light Tuna: Pink Salmon:
5 oz. 5 oz. 12 oz. 6 oz.
7.5 oz. 14.75 oz.
H. REGULAR PEANUT BUTTER : 16-18 oz. jars only. Smooth or crunchy, no spreads. No organic.
PriceStore brand
Other Highest price
I. GRAINS : approved bread whole grain/wheat 16 oz. loaves. No organic.
16 oz. Bread: PriceAunt Millie’s:
Best Choice: Bunny:
Butternut: Family Choice:
Healthy Life: Holsum: Kroger: Meijer:
Nature’s Own: Roman Meal:
Sara Lee: Classic Schnuck’s: Schwebel:
Spartan: Sunbeam:
Village Hearth: Wonder:
16 oz. Tortilla: No Organic PriceBest Choice: Whole Wheat
Best Choice: Corn Carlita: Corn
Carlita: Whole Wheat Whole Grain Chi-Chi’s: Whole Wheat
Chi-Chi’s: Corn Don Pancho: Whole Wheat
Don Pancho: Corn Food Club: Whole Wheat
Guerrero: Whole Wheat Guerrero: Corn
Kroger: Whole Wheat La Banderita: Whole Wheat
La Banderita: Corn La Burrita: Corn
Meijer: Whole Wheat 8” Fajita Size Mission: Whole Wheat
Mission: Corn Ortega: Whole Wheat
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Schnucks: Whole Wheat Shurfresh: Corn/Maiz Tortillas 6”
Spartan: Whole Wheat 8” Fajita Style
Brown Rice:14-16 oz. No organic.Price
Brown Rice Brown Rice
Whole Wheat Pasta: 16 oz. No organic.Price
Whole Wheat Pasta Whole Wheat Pasta
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J. 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: Price Size Price Size*Cheerios ® Regular 18 oz. 36 oz.
*Multi Grain Cheerios 18 oz. 36 oz.Corn Chex 18 oz.Rice Chex 18 oz.
*Kix ® (regular) 18 oz.Dora the Explorer ® (regular) 18 oz.
Kellogg’s: Price Size Price SizeCrispix ® 18 oz.
Corn Flakes ® 18 oz. 36 oz.*Frosted Mini Wheats ® Big Bite 18 oz.*Frosted Mini Wheats ® Original 18 oz. 36 oz.
*Mini Wheats ® Unfrosted 18 oz.*Scooby-Doo ® 18 oz.
*All-Bran® Wheat Flakes 18 oz.Rice Krispies® (regular) 18 oz.*Special K ® (original) 18 oz.
Post®: Price Size Price Size*Grape Nut ® Flakes 18 oz.
Honey Bunches of Oats®:Honey Roasted 18 oz. 36 oz.
*Vanilla Bunches 18 oz.Banana Blueberry 18 oz.
Almonds 18 oz. 36 oz.Cinnamon Bunches 18 oz.
Malt-O-Meal: Price Size Price Size*Frosted Mini Spooners® 18 oz. 36 oz.
*Strawberry Cream Mini Spooners® 18 oz. 36 oz.*Blueberry Mini Spooners® 18 oz. 36 oz.
Oat Blenders® Honey 18 oz. 36 oz.Crispy Rice® 18 oz. 36 oz.
Quaker®: Price Size*Life® 18 oz.
HOT CEREALS: Price Size Price SizeMalt-O-Meal® 18 oz. 36 oz.
*Cream of Wheat® Whole Grain 18 oz.*Quaker Instant Oatmeal Original 11.8 oz.
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K. 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.: Brand Price
Apple Juice 64 oz.:
Grape Juice 64 oz.
Grapefruit Juice 64 oz.:
Pineapple Juice 64 oz.:
Tomato and Vegetable Juice 64 oz.:
Other Juices 64 oz.:Juicy Juice, any flavor
Old Orchard 100% Juice
Refrigerated 64 oz. Juice:
Orange Juice 64 oz.: Brand Price
Grapefruit Juice 64 oz.:
L. JUICE CONCENTRATES : Frozen only. No organic.
Frozen 11.5-12 oz. Juice:
Orange Juice: Brand Price
Grapefruit Juice:
Apple Juice:
Grape Juice:
Other:Welch’s any flavor with
yellow tab
Old Orchard any flavor with green tab
Dole 100% Juice(any flavor)
Shelf Stable ConcentrateWelch’s 100% Juice
(any flavor)
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M. INFANT CEREAL : 8 oz. any grain or multi-grain. (except Quinoa). No organic.
Brand Price
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N. BABY FOOD: No organic.
4 oz. Fruits & VegetablesBrand Price
2.5 oz. Meat, may include broth or gravy:
O. INFANT FORMULA :
Is your store also a pharmacy? Yes No
If 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 http://www.in.gov/isdh/files/Indiana_WICFormulary.pdf within 2 working days? Yes No
Who is the WIC contact for special order formula at your store?
Name: Title: Phone: Email:
List PER CAN prices except where multiple units are indicated. NOTE: *Bolded items are required to be in stock in stores.
Powder Size as Specified Ready to Feed Liquid ConcentrateSize Price Size Price Size Price
Gerber Good Start Gentle *12.7 oz. 8.45 oz. 4 pk. *12.1 oz. Gerber Good Start Soothe *12.4 oz.
Gerber Good Start Soy *12.9 oz. 8.45 oz. 4 pk. 12.1 oz.
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P. PRESCRIPTION FORMULA
Reminder: 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 Specified Ready to Feed Liquid Concentrate Case
Size Price Size Price Size Price Size Price
Boost (any flavor) 8 oz. 6 pack Boost Kid Essentials 1.0 cal. (any flavor) 8.25 oz. 4 pack
EleCare for Infants w/DHA& ARA 14.1 oz. Enfamil Nutramigen w/Enflora 12.6 oz.
Enfamil Nutramigen quart 13 oz. Enfamil EnfaCare 12.8 oz. quart *2 oz. /48/case
Ensure 8 oz. 6 pack Neocate Infant w/DHA&ARA 14.1 oz.
Neocate Junior 14.1 oz. Pediasure (any flavor) 8 oz. 6 pack
Pediasure w/Fiber (any flavor) 8 oz. 6 pack Pediasure 1.5 cal (any flavor) 8 oz. can/24/case
Pediasure Peptide 1.0 cal (any flavor) 8 oz. can/24/case Similac Expert Care Alimentum 16 oz. quart
Similac Expert Care NeoSure 13.1 oz. quart
*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 http://www.in.gov/isdh/files/Indiana_WICFormulary.pdf .
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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 http://www.ascr.usda.gov/complaint_filing_cust.html, 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 [email protected].
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:
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