Form FNS-648 WIC LOCAL AGENCY DIRECTORY REPORT

Print

FORM APPROVED OMB NO. 0584-0431
TYPE OF REPORT

U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE

ADDITION

WIC LOCAL AGENCY DIRECTORY REPORT

DELETION

CHANGE

EFFECTIVE DATE (MONTH & YEAR)

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 0584-0431. The time required to complete this collection is
estimated to average .17 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection.
1. STATE

2. 10-DIGIT CODE

3. REPORT
LOCAL AGENCY NAME
ADDRESS
ADDRESS
CITY
STATE

ZIP CODE

TELEPHONE NUMBER

Form FNS-648 (02-02) Previous editions may be used until supply is exhausted

SBU

Electronic Form Version Designed in Adobe 7.1 Version

INSTRUCTIONS FOR COMPLETING FORM FNS-648
PURPOSE
Each State agency administering the WIC Program shall inform FNS of additions and deletions of local agencies administering
the WIC Program and local agency address changes as these events occur. FNS will use this information to maintain a current
local agency directory.

TYPE OF REPORT
Place an "X" in the block which describes the action, i.e., addition refers to adding to the database a new local agency selected
to administer the WIC Program, deletion refers to deleting from the database an existing WIC local agency which has discontinued
its operations, and change refers to address changes for existing WIC local agencies.

EFFECTIVE DATE
Enter the corresponding month and calendar year in which the local agency began or ended WIC operations or officially changed
its address.

1. STATE. Enter the State agency name.
2. 10-DIGIT CODE. Enter the 10-digit identification code. The code is formatted as follows: SS=State FIPS Code, DDD=

Department Classification Code, NN=Numeric Counter, XXX=Existing local agency identifier used in previous year(s) that was
assigned by FNS. When adding a new local agency, contact FNS for assignment of 10-digit code.

3. LOCAL AGENCY NAME, ADDRESS, CITY, STATE, ZIP AND TELEPHONE. Enter the current name, address and 10digit telephone
number for the local agency. Abbreviations are permitted, where necessary.

SUBMISSION
State agencies shall submit these reports to the applicable Food and Nutrition Service Regional Office as changes occur but not
later than 60 days following the change, i.e., a change which occurs on April 30th shall be reported by June 30th. The Regional
Office shall than enter the local agency information into the National Master database.