HomeMy WebLinkAboutknow-your-rights-responsibilities-engCalifornia Department of Public Health—WIC ProgramState of California —Health and Human Services Agency
Know Your Rights and Responsibilities
Fair Treatment
• Standards for eligibility and participation in
the WIC Program are the same for everyone,
regardless of race, color, national origin, age,
handicap, or sex.
• If you are found ineligible for WIC, you will be
given the reasons in writing, and you will be
advised of your rights to a fair hearing.
Your Rights
You Will Receive
• WIC benefits, which you can use to supplement
your monthly food budget with healthy foods
• Helpful tips for a nutritious diet and breastfeeding
• Information about other health services available
(like health care and immunizations), including
the locations for these services
• Encouragement to use these tips and other
services
Buy WIC-Authorized Foods
• It is important to use your WIC benefits
every month.
• Use your WIC benefits at WIC-authorized
grocery stores.
• Bring your WIC Card to the grocery store every
time you shop for WIC foods.
• Buy only WIC-authorized foods with your
WIC benefits.
• Use the foods only for the person on
the program.
Be Honest
• Provide current and truthful eligibility information
to WIC staff at all times.
• Promptly report any changes in your income,
family size, address and/or phone number.
• Report any changes in your eligibility for
MediCal, CalWORKS (TANF) or CalFresh.
• Do not sell, trade, or attempt to sell or trade your
WIC benefits, food, or infant formula, in person,
in print, or online. You may be disqualified for
this type of violation.
Be Courteous
• Keep your WIC appointments or call ahead
when you need to reschedule.
• Bring all requested documents to all WIC
appointments.
• Treat WIC staff and grocery store staff with
courtesy and respect.
• Do not threaten or physically harm anybody in
the WIC office or the grocery store.
I Understand…
• This certification form is being submitted
in connection with the receipt of Federal
assistance. Program officials may verify
information provided. I understand that
intentionally making a false or misleading
statement or intentionally misrepresenting,
concealing, or withholding facts may result in
paying the State agency, in cash, the value of
the food benefits improperly issued to me and
may subject me to civil or criminal prosecution
under State and Federal law.
• Dual participation (receiving benefits from more
than one WIC office at a time) is illegal and can
result in disqualification from WIC.
Your Responsibilities
This institution is an equal opportunity provider. #930118CDPH 4132 (EN) Rev 05/19
• If I am told that I am not eligible for WIC, I will
be given the reasons in writing.
• I may appeal any decision made by the local
WIC agency regarding my eligibility.
• I will receive 15 days’ notice if my certification is
about to expire, or if I am about to be terminated
from the program.
• If I ask somebody else to substitute for me in a
WIC-related activity, I will explain these rights
and responsibilities to them.
• If I plan to move, I can transfer my WIC
benefits, and my WIC local agency can help me
with the paperwork.
The WIC Program Does Not
Discriminate
In accordance with Federal civil rights law and
U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies,
offices, and employees, and institutions
participating in or administering USDA programs
are prohibited from discriminating based on
race, color, national origin, sex, disability, age, or
reprisal or retaliation for prior civil rights activity
in any program or activity conducted or funded
by USDA.
Persons with disabilities who require alternative
means of communication for program information
(e.g. Braille, large print, audiotape, American Sign
Language, etc.), should contact the Agency (State
or local) where they applied for benefits. Individuals
who are deaf, hard of hearing or have speech
disabilities may contact USDA through the Federal
Relay Service at (800) 877-8339. Additionally,
program information may be made available in
languages other than English.
To file a program complaint of discrimination,
complete the USDA Program Discrimination
Complaint Form, (AD-3027) found online at:
www.ascr.usda.gov/complaint_filing_cust.html, and
at any USDA office, or write a letter addressed to
USDA and provide in the letter all of the information
requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by:
(1) mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov
This institution is an equal opportunity provider.
I have read this entire document. I have been advised of my rights and responsibilities under
the Program. All questions I had (if any) have been answered to my satisfaction. I certify that
the information I have provided is true and correct, to the best of my knowledge.
Signature of family representative/caretaker Date [Family ID]
Staff Use Only:Local agency staff has reviewed the Know Your Rights and
Responsibilities form with the family representative/caretaker, and
any and all questions have been answered to their satisfaction.