Fns-699

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THE INTEGRITY PROFILE (TIP) REPORT FORM

FORM APPROVED OMB NO. 0584-0401

Contact Person:
First Name:

Last Name:

Phone:

Aggregate Data
Number of Vendors not selected during the Fiscal Year, due to failure to meet selection and/or limitation criteria was:

Number of Vendors with scanners:

Number of Vendors with scanners that can identify WIC Authorized foods versus non-WIC foods is:

Provide any other special information needed to clarify or interpret the TIP data:

OMB STATEMENT - According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0401.
The time required for completing this collection is estimated to take 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering the data needed, and completing and reviewing the information collection.

Form FNS-699 (05-05) Previous editions are obsolete

SBU

Electronic Form Version Designed in Adobe 7.1 Version