Current, Former, and Recently Denied WIC Participants (Individuals/Households)

APPENDIX B4.b

DENIED APPLICANT SURVEY VERSION B (INFANT/CHILD) - ENGLISH

Instructions for Reviewers

The Denied Applicant Survey will be administered by trained Field Interviewers (FIs). After FNS approves the final draft, the research team will begin implementing the survey in a Computer Assisted Personal Interview (CAPI) format programmed for use on study laptops. This paper version approximates the layout of the CAPI questionnaire and includes notes indicating how the CAPI system will automatically route the FI to the appropriate questions or data entry forms, or performs specified calculations (these notes appear in the paper version in RED, CAPITALIZED text but will not appear in the CAPI version). In addition, the CAPI version will be programmed to pre-populate certain data about each applicant sampled for the Denied Applicant Survey; these data elements appear in Table 2 on the next page.

The NSWP-III version of the Denied Applicant Survey is similar in many aspects to the Certification Survey: it includes items needed to make an independent assessment of an applicant’s eligibility under four criteria: proof of identity; proof of residency; categorical eligibility; and income eligibility. However, the Denied Applicant Survey differs substantially from the version used in NSWP-II. The version fielded in NSWP-II was a brief telephone survey that relied heavily on self-report, and no documentation. For example, respondents were asked whether they knew the reason WIC had denied their application and, if so, whether they agreed with WIC’s determination of their ineligibility.

The survey is organized into the following modules:

Table 1: Denied Applicant Survey Modules
Name	Purpose
Identity	Document proof of identity
Residency	Document proof of residency
Category	For Infant or Child applicants, establish participant category
Income	Determine the size of the applicant’s family economic unit; Collect documentation of income sources
End survey	Thank respondent and conclude survey

FIs will administer the five numbered modules in order.

Text that FIs read aloud (questions, response options where indicated) appear in regular text, while on-screen instructions to FIs appear in CAPITALIZED TEXT.

Table 2. Data Pre-Populated into the Computer-Assisted Personal Interview (CAPI) system for each Applicant in the Sample
Variable	Description
APPLICANT LAST NAME	WIC applicant’s last name
APPLICANT FIRST NAME	WIC applicant’s first name
CAREGIVER LAST NAME	Last name of adult (parent or legal guardian) if APPLICANT is infant or child
CAREGIVER FIRST NAME	First name of adult (parent or legal guardian) if APPLICANT is infant or child
STREET	street name and number (from WIC agency)
CITY	city (from WIC agency)
STATE	state (from WIC agency)
ZIP	zipcode (from WIC agency)
STATE_ID	State WIC Agency identifier
LOCAL_ID	Local WIC Agency identifier
CLINIC_ID	Local clinic identifier
ITO	Yes/No, denied applicant is from an ITO or an LWA run by an Indian organization or Indian Health Service
APP_DATE	Date of most recent application (mm/dd/yyyy)
MONTH OF APP_DATE	The name of the month of most recent application date (CAPI will calculate from APP_DATE)
ADJUNCT_ELIG	IF AVAILABLE FOR DENIED APPLICANT: yes/no, applicant was adjunctively income eligible for WIC
ADJUNCT_PROGRAM	IF AVAILABLE FOR DENIED APPLICANT: name of program that made ADJUNCT ELIG=yes
MIGRANT	Yes/No, applicant is a migrant worker

INTRO: Hi. Thanks for agreeing to do this survey. As you know, we are conducting this survey among people who were turned down for WIC benefits so that we can see if the agency is following correct procedures. We will keep your responses private to the extent allowed by law. Because the interview is private, it cannot change the decision made by WIC. However, if you think that the local WIC agency may have made a mistake, or if your circumstances have changed since you last applied, you may want to apply for WIC benefits for your infant or child again. After we finish, I will give you a $25 Visa debit card to thank you for your participation.

Before we start, we need to review this form together. It tells you about your rights as a study participant. It tells you how we will protect your privacy and how we will use your answers.

READ INFORMED CONSENT STATEMENT AND GET SIGNED CONSENT BEFORE PROCEEDING.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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-XXXX. The time required to complete this information collection is estimated to average 39 minutes (0.65 hours) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.

IDENTITY

Just to be sure we are both on the same page, I am going to be asking questions about the day you applied for WIC on [APP_DATE], on behalf of your infant or child.

1. “The first question about is identification. Thinking back to [APP_DATE] when you applied for WIC, did you show something with your name or photograph, some other type of identification for your child or for yourself?”

• YES, FOR CHILD GO TO 1A

• YES, FOR ME GO TO 1A

• BOTH GO TO 1A

• NO GO TO 1B

• DON’T RECALL GO TO 1B

1A.“What forms of identification did you show when you applied for WIC on [APP_DATE]?” [IF APPLICANT HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID FROM LIST.]

• REMEMBERS TYPE/S SHOWN MARK TYPE/S IN “ID SHOWN AT WIC” COLUMN/S BELOW AND GO TO 1E

• DON’T RECALL GO TO 1E

Identification proofs shown at WIC agency				INFANT or CHILD ID shown at WIC	CAREGIVER ID shown at WIC
Birth certificate w/infant/child’s name					
Hospital or immunization record, hospital ID bracelet w/infant/child’s name					
U.S. or foreign passport w/photo and infant/child’s name					
Social Security or Green card for infant/child (or other Immigration document with name)					
Letter from government agency (including WIC) w/ infant/child’s name					
WIC ID Card or WIC document with infant/child name or caregiver name					
PARENT/GUARDIAN ONLY: School, military, bus pass ID (or work ID for adult) w/photo & name					
PARENT/GUARDIAN ONLY: Driver’s license w/photo & name					
State- or tribal-issued license or ID w/photo & name					
OTHER: SPECIFY					
FI Notes

1B “Was there any reason you were unable to show ID when you applied for WIC on APP_DATE?”

DO NOT READ LIST. MULTIPLE RESPONSES OK

 FORGOT TO BRING IT

 DIDN’T KNOW WHAT ID TO BRING

 THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE

 DIDN’T HAVE ANY (PROBE: “Why didn’t you have any ID then?”)

 ID WAS STOLEN

 HOMELESS

 LOST MY WALLET/PURSE/ID

 LOST ID IN A FIRE, FLOOD, OTHER DISASTER

 WAS EVICTED AND LOST MY ID, OTHER PROPERTY

 LEFT PARENTS’/PARTNER’S HOME /NO ACCESS TO ID

 OTHER (SPECIFY: )

 DON’T RECALL/DON’T KNOW

 NONE OF THE ABOVE

1C. “Do you, or does anyone in your household, work on farms and move from place to place as the season changes?” IF NECESSARY: “WIC agencies have special rules for families that include a migrant farmworker who moves around the country depending on where there is work based on the growing season.”

• YES (MIGRANT FARMWORKER)

• NO

1D. “Did you go back to the WIC clinic sometime after [APP_DATE] with identification?

• YES GO TO 1E

• NO GO TO NEXT MODULE

1E. “Can you show me the same form/s of identification that you showed WIC, or some other type of ID/s?”

• YES GO TO 1F

• NO GO TO NEXT MODULE

1F. DOES NAME ON ID (FOR INFANT/CHILD AND/OR PARENT/GUARDIAN) MATCH SAMPLE INFORMATION?

• YES MARK TYPE IN “ID SHOWN DURING SURVEY” AND GO TO NEXT MODULE

• NO “The name on this ID doesn’t match my records. Can you show me another form of ID that has your name?”

• PARENT MARRIED, DIVORCED OR OTHER LEGAL NAME CHANGE SINCE APP_DATE

• NO VALID IDENTIFICATION GO TO NEXT MODULE

Identification proofs		INFANT or CHILD ID shown during survey	CAREGIVER ID shown during survey
Birth certificate w/infant/child’s name			
Hospital or immunization record, hospital ID bracelet w/infant/child’s name			
U.S. or foreign passport w/photo and infant/child’s name			
Social Security or Green card for infant/child (or other Immigration document with name)			
Letter from government agency w/ infant/child’s name			
WIC ID Card or WIC document with infant/child name (EBT cards are NOT valid proof of identity)			
PARENT/GUARDIAN ONLY: School, military, bus pass ID (or work ID for adult) w/photo & name			
PARENT/GUARDIAN ONLY: Driver’s license w/photo & name			
State- or tribal-issued license or ID w/photo & name			
OTHER: SPECIFY			
FI Notes

RESIDENCY: GEOGRAPHIC STATE

IF APPLICANT OR CAREGIVER LIVES IN INDIAN VILLAGE OR PUEBLO, CAPI WILL SKIP TO “ALTERNATE PROOF OF RESIDENCY.” ELSE CAPI WILL CONTINUE WITH RESIDENCY: GEOGRAPHIC STATE PROCEDURE.

IF IDENTIFICATION SHOWN AS PROOF OF IDENTITY HAS ADDRESS AND IS AN ACCEPTED PROOF OF RESIDENCY, MARK OFF THE TYPE OF RESIDENCY PROOF IN TABLE BELOW AND SKIP TO INCOME ELIGIBILITY MODULE. OTHERWISE GO TO QUESTION 2.

2. “Thinking back to [APP_DATE], when you applied for WIC, did you to show something with your name and address or with your child’s name and home address to prove where you live?”

• YES GO TO 2A

• NO GO TO 2B

• DON’T RECALL GO TO 2B

2A. “What did you show that had your home address?”

• REMEMBERS PROOF SHOWN MARK IN “SHOWN AT WIC” COLUMN BELOW AND GO TO 2E

• DON’T RECALL GO TO 2E

Residency proofs			Shown at WIC appointment (self-reported)
Utility bill (cable TV, electric/gas, water, sewer, garbage pickup) w/applicant name & address			
Rent/mortgage receipt or lease w/applicant name & address			
Mail (letter and/or postmarked envelope) received w/applicant name & address			
Voter’s registration card w/applicant name & address			
[IF STATE ALLOWS] Driver’s license, State or Tribal ID w/applicant name and address			
[OTHER STATE ALLOWED RESIDENCY PROOF]
Other: SPECIFY:			
FI Notes		FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

2B. “Was there any reason you were unable to show proof of where you and your child lived when you applied for WIC on [APP_DATE]?”

DO NOT READ LIST. MULTIPLE RESPONSES OK

 FORGOT TO BRING IT

 DIDN’T KNOW WHAT TO BRING

 THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE

 DIDN’T HAVE ANY (PROBE: “Why didn’t you have any proof of your address then?”)

 WAS STOLEN

 HOMELESS

 LOST MY WALLET/PURSE/ID

 LOST IN A FIRE, FLOOD, OTHER DISASTER

 WAS EVICTED AND LOST MY BELONGINGS

 LEFT PARENTS’/PARTNER’S HOME/NO ACCESS TO PROOF

 OTHER (SPECIFY: )

 DON’T RECALL/DON’T KNOW

 NONE OF THE ABOVE

2C. IF ITEM 1C WAS ADMINISTERED GO TO 2D. OTHERWISE ASK:

“Do you, or does anyone in your household, work on farms and move from place to place as the season changes?” IF NECESSARY: “WIC agencies have special rules for families include a migrant farmworker who moves around the country depending on where there is work based on the growing season.”

• YES (MIGRANT FARMWORKER) GO TO 2D

• NO GO TO 2D

2D. “Did you go back to the WIC clinic sometime after [APP_DATE] with something proving where you and your child lived?

• YES GO TO 2E

• NO GO TO NEXT MODULE

2E. “Can you show me that same document or something else with your name and home address now?” [IF NECESSARY: such as a utility bill, lease, or letter with your name and address?”] [IF RESPONDENT HAS TROUBLE WITH THIS REQUEST, READ SOME OF THE ACCEPTABLE TYPES OF RESIDENCY PROOF FROM LIST. MAIL MUST HAVE RESIDENTIAL ADDRESS. P.O. BOX DOES NOT = PROOF OF RESIDENCY. RURAL ROUTE BOX NUMBER IS ACCEPTABLE RESIDENTIAL ADDRESS.

• YES GO TO 2F

• NO GO TO NEXT MODULE

2F. DO NAME AND ADDRESS MATCH SAMPLE INFORMATION?

 YES MARK PROOF SHOWN DURING SURVEY AND GO TO NEXT MODULE

 NAME IS DIFFERENT BUT ADDRESS MATCHES GO TO 2G

 NAME MATCHES BUT ADDRESS IS DIFFERENT GO TO 2H

 NAME AND ADDRESS ARE BOTH DIFFERENT GO TO 2H

Residency proofs [CHECK AT LEAST ONE]			Shown during survey
Utility bill (cable TV, electric/gas, water, sewer, garbage pickup) w/applicant name & address			
Rent/mortgage receipt or lease w/applicant & address			
Mail (letter and/or postmarked envelope) received w/applicant & address			
Voter’s registration card w/applicant’s name & address			
[IF STATE ALLOWS] Current driver’s license, State or Tribal ID w/applicant’s name and address			
[OTHER STATE ALLOWED RESIDENCY PROOF]			
Other: SPECIFY:			
FI Notes		FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

2G. (NAME IS DIFFERENT BUT ADDRESS MATCHES): “This has an address, but someone else’s name. Do you have something with your name and address?”

 YES MARK PROOF SHOWN DURING SURVEY AND GO TO NEXT MODULE

 ADDRESS MATCHES BUT APPLICANT MARRIED, DIVORCED OR OTHER LEGAL NAME CHANGE SINCE APP_DATE:

GO TO NEXT MODULE

 ADDRESS IS DIFFERENT BUT NAME MATCHES GO TO 2H

 NAME AND ADDRESS ARE BOTH DIFFERENT GO TO 2H

 NO CURRENT PROOF OF RESIDENCY GO TO NEXT MODULE

2H. (ADDRESS DIFFERS OR NAME AND ADDRESS DIFFER): “Ok, the [name and] address on this document doesn’t match my records. Have you moved since APP_DATE?”

• YES (RECENTLY MOVED) ENTER INFO BELOW AND GO TO NEXT MODULE

• NO (DID NOT RECENTLY MOVE) GO TO 2I

State:

ZIP:

ADDRESS IS A STREET ADDRESS (Not PO Box)?

 Yes  No

2I. “Do you have something with your name and home address such as a utility bill, lease, or something that was recently mailed to you?”

• YES REVERSE TO 2F

• NO GO TO NEXT MODULE

RESIDENCY: ALTERNATE PROCEDURE (ITO/REMOTE INDIAN VILLAGE/PUEBLO)

ALTERNATE PROCEDURE APPLIES ONLY IF APPLICANT LIVES ON TRIBAL LAND OR IN REMOTE INDIAN VILLAGE OR PUEBLO. ELSE USE RESIDENCY: GEOGRAPHIC STATES.

ALTERNATIVE RESIDENCY PROCEDURE: GET VILLAGE NAME AND MAILING ADDRESS.

IF SAMPLE INFORMATION SHOWS A RESIDENTIAL STREET ADDRESS (NOT A PO BOX), GO TO ALT 2A.

IF SAMPLE INFORMATION SHOWS A PO BOX AND DOES NOT SHOW VILLAGE, GO TO ALT 2B.

IF SAMPLE INFORMATION DOES NOT SHOW A PO BOX AND SHOWS A VILLAGE, GO TO ALT 2B.

IF SAMPLE INFORMATION SHOWS A PO BOX AND SHOWS A VILLAGE, GO TO ALT 2D.

ALT 2A. “When you applied for WIC in [MONTH_OF_APP_DATE], did you show a document with you and your child’s home address?”

YES ENTER PROOF BELOW

 NO STREET ADDRESS, TRIBAL LAND OR REMOTE VILLAGE/PUEBLO GO TO ALT 2B

NO GO TO ALT 2D

Residency proof [CHECK AT LEAST ONE]			Shown during survey
Utility bill (cable TV, electric/gas, water, sewer, garbage pickup) w/applicant name & address			
Rent/mortgage receipt or lease w/applicant & address			
Mail (letter and/or postmarked envelope) received w/applicant & address			
Voter’s registration card w/applicant’s name & address			
[IF STATE ALLOWS] Driver’s license, State or Tribal ID w/applicant’s name and address			
[OTHER STATE ALLOWED RESIDENCY PROOF]			
Other: SPECIFY:			
FI Notes		FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

ALT 2B.	“What is the name of the town, village or pueblo where you live?”
Village from Sample Information: [VILLAGE]		Matches Sample Info?
Village		Yes	No

 REFUSES

IF VILLAGE NAME GIVEN DOES NOT MATCH SAMPLE INFORMATION, GO TO ALT 2C.

IF VILLAGE NAME MATCHES SAMPLE INFORMATION, GO TO ALT 2D.

IF VILLAGE IN SAMPLE INFORMATION is missing, GO TO ALT 2D

IF APPLICANT RELUCTANT TO GIVE VILLAGE NAME, GO TO ALT 2D.

ALT 2C(i). “My records say that you were living in [VILLAGE]. Is there another name for the place you lived at the time of your application appointment?

• YES (RECORD NAME:____________________) GO TO ALT 2D

• NO GO TO ALT 2C(ii)

ALT 2C(ii). Did you recently move?”

• YES (RECENTLY MOVED) GO TO ALT 2D

• NO (DID NOT RECENTLY MOVE) GO TO ALT 2D

ALT 2D. MAILING ADDRESS: “What is your current mailing address?”

Mailing address from SAMPLE INFORMATION
P.O. Box or Street Address	P.O. Box NN	State	MN	ZIP	ZZZZZ
City	Anywhere
IF MAILING ADDRESS DIFFERENT FROM SAMPLE INFORMATION
Gave mailing address	 Yes  No
City		State		ZIP

IF MAILING ADDRESS MATCHES SAMPLE INFORMATION, GO TO NEXT MODULE. IF NO MAILING ADDRESS IN SAMPLE INFORMATION OR RELUCTANT TO GIVE MAILING ADDRESS, GO TO NEXT MODULE.

IF MAILING ADDRESS GIVEN DOESN’T MATCH SAMPLE INFORMATION, GO TO ALT 2E.

ALT 2E. (CHANGE OF MAILING ADDRESS) “Did you recently change your mailing address?”

• YES GO TO NEXT MODULE

• NO GO TO NEXT MODULE

FI Notes



FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

PARTICIPANT CATEGORY

3. “Next, I’d like to confirm your child’s date of birth. When was [NAME OF INFANT/CHILD APPLICANT] born?”

ENTER DOB: mm/dd/yyyy. READ THE ENTIRE BIRTH DATE BACK TO APPLICANT TO CONFIRM ENTRY.

CAPI WILL CALCULATE THE APPLICANT’S AGE AS OF APP_DATE TO DETERMINE WHETHER THE APPLICANT QUALIFIED AS AN INFANT OR CHILD

THE APPLICANT COULD HAVE QUALIFIED AS INFANT IF A OR B WAS TRUE ON APP_DATE:

1. THE APPLICANT WAS ≤ 12 MONTHS ON APP_DATE, OR

2. THE APPLICANT’S APP_DATE FELL ON OR BETWEEN THE BIRTHDATE + 1 YEAR AND THE LAST DAY OF THE MONTH IN WHICH THE APPLICANT REACHED 1 YEAR OF AGE. EXAMPLE:

John Doe was born on April 2, 2016. John Doe has never received WIC before. The most recent application date was April 10, 2017 and he could have been certified as an infant, even though he was 12 months, 8 days old. The last day of the month equal to John Doe’s DOB + 1 year is April 30, 2017. CAPI would determine that the participant category was correct. (Although unusual for a WIC agency to certify John Doe as an infant for the remainder of the month, it is technically possible and consistent with WIC regulations.)

THE APPLICANT COULD HAVE QUALIFIED AS A CHILD IF A OR B OR C WAS TRUE ON APP_DATE:

1. THE APPLICANT WAS ≤ 60 MONTHS AND > 12 MONTHS ON APP_DATE, OR

2. THE APPLICANT’S APP_DATE FELL ON OR BETWEEN THE BIRTHDATE + 60 MONTHS AND THE LAST DAY OF THE MONTH IN WHICH THE APPLICANT REACHED 60 MONTHS OF AGE, OR

3. (NOTE THAT WIC REGULATIONS (246.7(g)(3)) ALLOW LOCAL AGENCIES TO SHORTEN OR EXTEND A CURRENT CERTIFICATION PERIOD FOR AN INFANT OR CHILD UP TO 30 DAYS IF THERE IS DIFFICULTY SCHEDULING A CERTIFICATION APPOINTMENT): THE APPLICANT WAS < 12 MONTHS AND THE APP_DATE FELL ON OR BETWEEN THE LAST DAY OF THE MONTH IN WHICH THE APPLICANT TURNED 11 MONTHS OF AGE AND THE BIRTHDATE + 1 YEAR. EXAMPLE:

Jane Doe was born on 12-25-16 and Jane’s mother was having difficulty scheduling an appointment to apply for WIC for Jane. Her local WIC agency suggests that she come to an appointment for Jane on 12-02-17. On that date, the agency could have determined that Jane was eligible as a CHILD even though Jane was only 11 months, 7 days old. The agency has discretion to shorten an infant certification period by up to 30 days (i.e., to December 1, 2017) or extend the child certification by this same amount. Jane was less than 12 months of age on her application date but the application date was between the last day of the month in which she turned 11 months (November 30) and her first birthday.

INCOME ELIGIBILITY

HOUSEHOLD ENUMERATION

Q1 “Next, I’m going to ask questions to understand your family situation, that is, your family size and income. Please tell me the names of all the people who were living or staying with [NAME OF INFANT/CHILD] in [MONTH OF APP_DATE] and whether they are related or not. I’ll record the names so that I can follow up with some questions. Be sure to include yourself, but please list only people who were living with [NAME OF INFANT/CHILD] in [MONTH OF APP_DATE].”

BEGIN WITH INFANT/CHILD APPLICANT. RECORD EACH NAME IN THE LIST BELOW. ENTER FIRST NAME ONLY

1. Who was living or staying with [INFANT/CHILD] in [MONTH OF APP_DATE]? PROBE FOR ADDITIONAL PERSONS: Anyone else?

2. Is [NAME] male or female?

3. How old is [NAME]?

4. What is [NAME]’s relationship to [NAME OF INFANT/CHILD]?

IF RELATIONSHIP IN Q4 = 20 (FOSTER PARENT), ASK Q4(FOSTER)

ASK Q4(FOSTER): “Just to confirm, is [NAME OF SAMPLED INFANT/CHILD APPLICANT] your/[NAME]’s foster child?”

• YES CAPI WILL ENUMERATE SAMPLED FOSTER INFANT/CHILD AS FAMILY ECONOMIC UNIT OF 1.

GO TO “ADJUNCTIVE OR AUTOMATIC ELIGIBILITY” SECTION

• NO REPEAT Q4 TO DETERMINE RELATIONSHIP, THEN CONTINUE WITH HOUSEHOLD ENUMERATION

Q1		Q2	Q3	Q4	Relationship Codes
NAME		GENDER 1=male 2=female	AGE in years	RELATIONSHIP TO INFANT/CHILD	6=parent 7=step-parent 8=legal guardian 9=brother/sister 10=grandparent	11=uncle/aunt 12=cousin 13=nephew/niece 14=parent in-law 15=brother-in-law/sister-in-law 16=other relative 17=non-relative 18=child in temporary care 19=foster child 20=foster parent 21=infant/child WIC applicant
SAMPLED INFANT/CHILD				21
ANYONE ELSE? 	FI MAY CLICK FOR ADDITIONAL ROWS AT ANY TIME DURING THE INTERVIEW. CAPI will add additional rows one at a time, up to 20 persons.

IF ANY Q4= 19 [HOUSEHOLD INCLUDES A FOSTER CHILD WHO SHOULD BE EXCLUDED FROM SAMPLED ECONOMIC UNIT], DISPLAY Q4FOSTER(ii): “When you applied for WIC, did you tell WIC that [NAME OF HOUSEHOLD MEMBER where Q4=19] is/are foster child/ren?  YES NO

FAMILY MEMBERS TEMPORARILY AWAY

“Other than people already listed, is there anyone who typically lived with you and your child, but who was temporarily away in [MONTH OF APP_DATE]?” (IF NECESSARY, PROBE: “For example, this could be a military service member on active deployment, someone who was in the hospital, a child who was away at school, a child who lived part-time with each parent. Is there anyone who typically lived here but who was temporarily away?”

• Yes GO TO Q1A (MEMBERS TEMPORARILY AWAY)

• No IF STATE EXCLUDES CHILDREN IN TEMPORARY CARE FROM ECONOMIC UNIT:

  • GO TO CHILDREN IN TEMPORARY CARE OF APPLICANT’S FAMILY

IF STATE INCLUDES CHILDREN IN TEMPORARY CARE FROM ECONOMIC UNIT:

• GO TO SHARED OR SEPARATE FINANCES

FAMILY MEMBERS TEMPORARILY AWAY=YES

1. [CONT’D] LIST NAME OF EACH PERSON TEMPORARILY AWAY

2. Is [NAME] male or female?

3. How old is [NAME]?

4. What is [NAME]’s relationship to [NAME OF INFANT/CHILD]?

Q4B. “Can you tell me the main reason this person was temporarily away in [MONTH OF APP_DATE]?” DO NOT READ LIST. PROBE FROM LIST IF NECESSARY. ENTER REASON IN COLUMN Q4B.

1=MILITARY MEMBER ON ACTIVE DEPLOYMENT

2=IN THE HOSPITAL/REHAB OR TREATMENT CENTER/HALFWAY HOUSE

3=LIVING AWAY AT SCHOOL (BOARDING SCHOOL, COLLEGE)

4=CHILD LIVES PART-TIME IN HOUSEHOLD GO TO Q4C

5=OTHER, SPECIFY [DO NOT LIST ANY PERSON WHO WAS IN JAIL/PRISON IN MONTH OF APP_DATE]

IF Q4B=4, CAPI WILL DISPLAY APPROPRIATE 4C QUESTION:

Q4C. IF Q4B=4: “Where does [NAME] live most of the time: READ LIST

1= More than half of the time here in this household

2= More than half of the time in another household

3=About equal time here and in another household

Members temporarily away
Q1A	Q2A	Q3A	Q4A	Relationship Codes		Q4B	Q4C
NAME	GENDER	AGE	RELATIONSHIP	6=parent 7=step-parent 8=legal guardian 9=brother/sister 10=grandparent	11=uncle/aunt 12=cousin 13=nephew/niece 14=parent in-law 15=brother-in-law/sister-in-law 16=other relative 17=non-relative 18=child in temporary care 19=foster child 20=foster parent	REASON TEMPORARILY AWAY (1-5)	If Q4B=4: WHERE CHILD LIVES MOST: enter 1, 2, or 3

IF STATE AGENCY INCLUDES CHILDREN IN TEMPORARY CARE IN FAMILY ECONOMIC UNIT, CAPI WILL SKIP THIS MODULE

IF STATE AGENCY EXCLUDES CHILDREN IN TEMPORARY CARE FROM FAMILY ECONOMIC UNIT, CAPI WILL DISPLAY THIS MODULE

CHILDREN IN TEMPORARY CARE OF THE DENIED APPLICANT’S FAMILY

“Sometimes, families will take in other children whose parents are temporarily away. Thinking back to [MONTH OF APP_DATE], were you or your family providing temporary care to any of the children you’ve listed [IF NECESSARY: “I am not referring to your foster child(ren)”]?

CAPI-FILLED LIST OF CHILDREN ≤14 YEARS OLD	IN TEMPORARY CARE?	IF IN TEMPORARY CARE = YES: “Was your family caring temporarily for this child because his/her parents were away on active military deployment?	“Did you receive any payments from this child’s parents while the child was in your care?” If so, how much?
NAME OF 1st CHILD	 Yes  No	 Yes, parents of child on active military deployment  No, other reason for temporary care	 Yes   No	$ _____	per month per week
NAME OF 2nd CHILD	 Yes  No	 Yes, parents of child on active military deployment  No, other reason for temporary care	 Yes   No	$ _____	per month per week
NAME OF 3rd CHILD	 Yes  No	 Yes, parents of child on active military deployment  No, other reason for temporary care	 Yes   No	$ _____	per month per week

IF COLUMN 2=YES, IN TEMPORARY CARE, CAPI WILL SET Q4 = 18 FOR THAT CHILD AND EXCLUDE THAT CHILD FROM FAMILY ECONOMIC UNIT

SHARED OR SEPARATE FINANCES

CAPI WILL AUTOMATICALLY DISPLAY NAME, GENDER, AGE AND (IF APPLICABLE) REASON TEMPORARILY AWAY OF EACH PERSON. INTERVIEWER WILL READ THE AGE-APPROPRIATE QUESTION AND SELECT RESPONSE IN COLUMN Q6:

“Next, I’m going to ask whether you shared income and expenses with each person who was living with [NAME OF INFANT/CHILD] in [MONTH OF APP_DATE].”

IF AGE OF HOUSEHOLD MEMBER ≥ 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH_OF_APP_DATE], you were sharing income and expenses as if you were a family – OR do you feel that you each kept your income and expenses and food separately?”

• Yes, shared: SELECT “SHARE LIKE FAMILY” FOR NAME

• No, kept separate: SELECT “SEPARATE” FOR NAME

• Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME

IF AGE OF HOUSEHOLD MEMBER < 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF APP_DATE], you were responsible for taking care of them as if you were all in the same family?”

• Yes, responsible for taking care of: SELECT “SHARE LIKE FAMILY” FOR NAME

• No, not responsible for taking care of: SELECT “SEPARATE” FOR NAME

• Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME

FOR MEMBERS TEMPORARILY AWAY, PROBE IF NECESSARY:

• NAME IS AGE ≥ 15 YEARS: “When [NAME] is here, do you and [NAME] share income and expenses?”

• NAME IS AGE < 15 YEARS: “When [NAME] is here, do you help take care of [NAME] as if you were all in the same family?”

PREFILLED					INTERVIEWER SELECTS
	Q1	Q2	Q3	Q4B	Q6
	NAME	GENDER	AGE	REASON TEMPORARILY AWAY	Family or Separate?1
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	(1-5 code)	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	(1-5 code)	 1=share like family  2=separate

PREGNANT FAMILY MEMBERS

P1. “Were you or another person in [NAME OF INFANT/CHILD APPLICANT]’s family pregnant when you applied for WIC on APP_DATE?

• Yes GO TO P2

• No GO TO Q7 ADJUNCTIVE ELIGIBILITY

P2. “Who was pregnant on APP_DATE?”
<SELECT NAME FROM Q1 LIST DROPDOWN MENU>	IF PREGNANT MEMBER SHARES FINANCES (Q6=1), GO TO P2A. IF PREGNANT MEMBER HAS SEPARATE FINANCES (Q6=2), GO TO P2D

P2A. “Were you/Was [NAME] expecting a single infant, twins or multiples?” (DO NOT READ OPTIONS)

• SINGLETON IF SHARED FINANCES CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT

• TWINS IF SHARED FINANCES CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT

• MULTIPLES [ENTER NUMBER FROM 3 OR HIGHER] IF SHARED FINANCES CAPI WILL ADD [N] TO FAMILY ECONOMIC UNIT

P2B. “Since that appointment have you/has [NAME] given birth?” (DO NOT READ OPTIONS)

• YES GO TO P2C

• NO [STILL PREGNANT OR PREGNANCY ENDED] GO TO P2D

P2C. “Have you already listed the infant/infants that you/that [NAME] gave birth to as part of your household above?” [CONFIRM THAT THE SAME NUMBER OF INFANTS FROM ITEM P2A ARE ALREADY LISTED IN HOUSEHOLD ENUMERATION CHART] (DO NOT READ OPTIONS)

BE AWARE THAT A “NO” RESPONSE COULD MEAN THAT THE BABY IS DECEASED/WAS STILLBORN, OR DOES NOT LIVE WITH THE APPLICANT (ADOPTED OR REMOVED FROM THE HOME BY THE STATE)

• YES, WITH [N] BABIES LISTED CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT

• NO: INFANT DECEASED, REMOVED FROM HOME, WAS NOT LIVING IN HOUSEHOLD ON APP_DATE – DO NOT LIST THE INFANT ANYWHERE

P2D. “Was anyone else pregnant on APP_DATE?”( IF NECESSARY: THESE QUESTIONS HELP DETERMINE THE CORRECT NUMBER OF PEOPLE IN YOUR HOUSEHOLD WHEN YOU APPLIED FOR WIC)

• YES IF YES, REVERSE TO P2 AND REPEAT P2-P2D AS NEEDED

• NO GO TO Q7 ADJUNCTIVE ELIGIBILITY

ADJUNCTIVE OR AUTOMATIC ELIGIBILITY

Q7. “When you applied for WIC on [APP_DATE], were you, your child, or another member of your family, participating in a benefits program such as Medicaid [OR STATE-SPECIFIC NAME OF MEDICAID PROGRAM(S)], SNAP, TANF or [NAME OF STATE PROGRAM(S)]?”

YES	“Can you show me a document to demonstrate participation in that program, such as an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT_PROGRAM] participant was eligible?”
WIC LOOKED UP MY/MY CHILD’S NAME IN PROGRAM ENROLLMENT LIST, WEBSITE OR BY CALLING RELEVANT AGENCY	“Ok, do you have an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT_PROGRAM] participant was eligible?”
NO	GO TO INCOME SOURCES
DON’T RECALL	GO TO INCOME SOURCES

IF RESPONDENT HAS DOCUMENTATION, ENTER INFORMATION IN TABLE BELOW

Documentation: Participation in Program Conferring Adjunctive/Automatic Income Eligibility
Adjunctive program	SNAP (Food stamps) TANF (welfare; transitional assistance) Medicaid Other program, SPECIFY:
Type of document shown:	NO DOCUMENTATION (self-report) Program document with dates of eligibility Award letter EBT transaction receipt no more than 30 days < APP_DATE EBT activity statement with deposit no more than 30 days < APP_DATE Other:
Name of program participant	<select name from CAPI-generated list of family EU members>
Start date of eligibility or enrollment		No start date/date unclear PROBE: Do you have anything that shows the dates of your participation?
Date eligibility or enrollment expires		 No expiration date/date unclear PROBE: Do you have anything that shows the dates of your participation?
Name of agency		Agency name not evident PROBE: Do you have anything that shows the agency name?

IF FIRST DATE OF ELIGIBILITY ON DOCUMENT IS MORE RECENT THAN APP_DATE, GO TO “PROOF TOO NEW.”

IF LAST DATE OF ELIGIBILITY OCCURRED BEFORE APP_DATE, GO TO “PROOF EXPIRED.”

IF NO PROOF, OR INFORMATION FROM DOCUMENT ENTERED, GO TO “OTHER BENEFITS PROGRAM.”

PROOF TOO NEW

“It looks like this document was issued after you applied for WIC on [APP_DATE]. Do you have anything else from this program with an active date before APP_DATE?”

• YES ENTER INFORMATION FROM CORRECTLY DATED PROOF OF PARTICIPATION IN ADJUNCT PROGRAM (CAPI WILL PRESENT A NEW TABLE FOR ENTERING INFORMATION FROM THE NEXT DOCUMENT SHOWN)

• NO GO TO OTHER BENEFITS PROGRAM

PROOF EXPIRED

“It looks like this document expired before you applied for WIC on [APP_DATE]. Do you have anything else from this program that shows that you were/your child was an active participant on [APP_DATE]?”

• YES ENTER INFORMATION FROM CORRECTLY DATED PROOF OF PARTICIPATION IN ADJUNCT PROGRAM (CAPI WILL PRESENT A NEW TABLE FOR ENTERING INFORMATION FROM THE NEXT DOCUMENT SHOWN)

• NO GO TO OTHER BENEFITS PROGRAM

OTHER BENEFITS PROGRAM

“Was anyone in your family enrolled in any other benefits programs when you applied for WIC on [APP_DATE]?” [IF NECESSARY, PROMPT “such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)]”]

• YES CAPI WILL REPEAT RESPONSE OPTIONS AND PROMPTS SHOWN ABOVE UNDER Q7 FOR FI TO ENTER INFORMATION ABOUT PARTICIPATION IN ANY OTHER PROGRAM THAT MAY CONFER ADJUNCTIVE INCOME ELIGIBILITY

• NO “OK, thank you. Let’s move on to income sources.” GO TO INCOME SOURCES

CAPI WILL GO TO INCOME SOURCES EVEN IF ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBLE: [Note for reviewers: Regardless of adjunctive income eligibility status, for denied applicants we will also collect income]

INCOME: ALTERNATE INCOME DETERMINATION PROCEDURE (INDIAN TRIBAL ORGANIZATIONS)

IF ITO=YES AND ALTERNATIVE INCOME PROCEDURE=YES, THE “ALTERNATE INCOME DETERMINATION PROCEDURE” APPLIES. OTHERWISE, CAPI SKIPS ALTERNATE PROCEDURE FOR INCOME DETERMINATION

CAPI PERFORMS A LOOKUP AGAINST TABLE OF INCOME ELIGIBILITY GUIDELINES (IEGs) BASED ON SIZE OF FAMILY ECONOMIC UNIT. CAPI DISPLAYS INCOME THRESHOLD [INCOME_MAX].

ID8 “On [APP_DATE], was your family’s income at or below $[INCOME_MAX]?”

YES	GO TO ID8A
NO	GO TO INCOME SOURCES (Q8a)

INCOME SOURCES

“Now I’m going to ask you about the income you and other members of your family were receiving when you applied on [APP_DATE] for your child to receive WIC. We want to assure you that we will protect your privacy. We will not include information that identifies you or your family in study reports. We will combine the income we collect with information from other people in this study from across the U.S. We won’t share personal information about you or your family with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community.”

Q8a. When you applied for WIC on [APP_DATE], were you or was anyone in your family unemployed – that is, had been working but stopped?

• Yes GO TO Q8b

• No GO TO INCOME SOURCES

IF RESPONDENT IS CONFUSED, PROBE: “Had you (or someone in your family) been working but lost a job or stopped working for some reason?”

Q8b.Who was unemployed then?	Q8c. About how long had you [had this person] been unemployed as of APP_DATE? READ LIST:
<select name from CAPI-generated list>	 Less than 30 days before APP_DATE  1 month or longer before APP_DATE
<select name from CAPI-generated list>	 Less than 30 days before APP_DATE  1 month or longer before APP_DATE
<select name from CAPI-generated list>	 Less than 30 days before APP_DATE  1 month or longer before APP_DATE

“Now I’ll start by asking about your sources of income, and then I’ll ask about sources of income for other members of your family. For each type of income, I may ask to see records or documents showing the dates you received that income and the amount you received. It’s important that we focus on income you or your family members were receiving at the time you applied for WIC in [MONTH_OF_APP_DATE].”

GO TO Q9A. CAPI WILL DISPLAY QUESTIONS Q9A-Q9E FOR ALL INCOME SOURCES FOR EACH PERSON IN THE FAMILY UNIT WITH SHARED FINANCES WHO IS AGED 15 OR OLDER (CALLED “ADULT FAMILY MEMBER”

NOTE FOR REVIEWERS:

On the pages that follow, different types of “proof of income documents” are listed for each income type. The preferred documents appear in underlined text: these documents are those that best meet guidance provided by WIC policy memoranda (#99-4, #2013-3). If a respondent cannot present one of the “preferred” documents, additional acceptable types of proof appear in light gray (non-underlined) text. Each income type also includes an “other” option, where a Field Interviewer may describe another type of document presented as evidence of the income amount reported, and an option to indicate that no documents were available. For each income type, even if documentation is not available, the FI will ask the respondent to report the amount and frequency of that income.

Q9A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE IN COLUMN A. CHECK ONLY IF YES.

Q9B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN 9C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Wages, salary or fees (EXCLUDING MILITARY PAY) Employer 1 Employer 2 Employer 3	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement 2017 income tax return, W-2, 1099 Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Wages, salary or fees (EXCLUDING MILITARY PAY) Employer 1 Employer 2 Employer 3	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement 2017 income tax return, W-2, 1099 Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Wages, salary or fees (EXCLUDING MILITARY PAY) Employer 1 Employer 2 Employer 3	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement 2017 income tax return, W-2, 1099 Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Tips, bonuses, or commissions (POSSIBLE LUMP SUM)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Employer statement Business records (for commissions) Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Tips, bonuses, or commissions (POSSIBLE LUMP SUM)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Employer statement Business records (for commissions) Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Income from self-employment (farm or non-farm) (NET INCOME)	From: mm/dd/yy To: mm/dd/yy	2017 income tax return, W-2, 1099 Business records Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Rental income (NET INCOME)	From: mm/dd/yy To: mm/dd/yy	Rental agreement, lease, other business records Rent check 2017 income tax return, W-2, 1099 Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Royalties (PROMPT FOR ITOs: per capita payments) (NET INCOME) (POSSIBLE LUMP SUM) (POSSIBLE EXCLUSION)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Deposit on bank statement 2017 income tax return, W-2, 1099 Business records Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Unemployment compensation	From: mm/dd/yy To: mm/dd/yy	Benefit letter/letter of determination Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
IF APPLICANT/FAMILY MEMBER INDICATES NO INCOME FROM UNEMPLOYMENT COMPENSATION BUT WAS UNEMPLOYED (Q8A), ASK: UE1. “Did you/[NAME] apply for unemployment benefits?” Yes GO TO UE2 No CONTINUE TO NEXT INCOME SOURCE UE2. “Was your/[NAME’S] application denied or approved?” DO NOT READ LIST Denied/turned down CONTINUE TO NEXT INCOME SOURCE Approved GO TO UE3 Have not heard back/never heard back CONTINUE TO NEXT INCOME SOURCE UE3. “Okay, you were/[NAME] was approved to get unemployment, but you have not/[NAME] has not received any income from unemployment compensation. Can you show me a copy of the approval letter?” Yes RECORD DATE OF LETTER AND AMOUNT OF BENEFITS AWARDED No CONTINUE TO NEXT INCOME SOURCE
Workers compensation	From: mm/dd/yy To: mm/dd/yy	Benefit letter/letter of determination Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Social security benefits	From: mm/dd/yy To: mm/dd/yy	Award letter from SSA Statement of benefits Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Federal SSI (Supplemental security income)	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
State SSI or State disability insurance	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Public assistance or TANF	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Alimony or child support (1st source)	From: mm/dd/yy To: mm/dd/yy	Check or check stub Support agreement Divorce/separation decree Court order Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Alimony or child support (2nd source)	From: mm/dd/yy To: mm/dd/yy	Check or check stub Support agreement Divorce/separation decree Court order Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Any government or private pension, annuity or survivor’s benefits	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Disbursement (payment) from an estate or trust	From: mm/dd/yy To: mm/dd/yy	Earnings statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Interest or dividends	From: mm/dd/yy To: mm/dd/yy	Earnings or dividend statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Withdrawals from a savings or investment account	From: mm/dd/yy To: mm/dd/yy	Withdrawal receipt/slip Earnings statement Withdrawal on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

A. Thinking back to the 30 days before [APP_DATE], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Veteran’s payments	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Military pay	From: mm/dd/yy To: mm/dd/yy	Leave and Earnings Statement (GO TO MILITARY PAY MODULE) Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Regular contributions from someone not in household	From: mm/dd/yy To: mm/dd/yy	Letter from payer, dated & signed Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Other income sources (SEE INCOME PROBE QUESTIONS)	From: mm/dd/yy To: mm/dd/yy	Earnings statement Benefit/award letter Letter from payer, dated & signed Deposit on bank statement 2017 IRS tax return, W2, 1099 Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

MILITARY PAY MODULE²

USING THE SERVICE MEMBER’S MILITARY LEAVE AND EARNINGS STATEMENT, ENTER THE INFORMATION BELOW. SOME PAY CODES WILL PROMPT YOU TO ASK CLARIFYING QUESTIONS THAT WILL AUTOMATICALLY DISPLAY. ANSWERING THE QUESTIONS WILL DETERMINE THE INCOME TREATMENT CODE IN THE RIGHTMOST COLUMN.

Last Name		First Name		MI	Pay Date	Branch	Period Covered
ENTITLEMENTS
A	Type		Amount		Income treatment codes
B	ENTER PAY CODE		$ .
C	ENTER PAY CODE		$ .		EXCLUDE: BAH
D	ENTER PAY CODE		$ .		EXCLUDE: OCONUS COLA
E	ENTER PAY CODE		$ .
F	ENTER PAY CODE		$ .		ANNUALIZE
G	ENTER PAY CODE		$ .
H	ENTER PAY CODE		$ .
I	ENTER PAY CODE		$ .		EXCLUDE: COMBAT PAY
J	ENTER PAY CODE		$ .
K	ENTER PAY CODE		$ .
L	ENTER PAY CODE		$ .
M	ENTER PAY CODE		$ .
N	ENTER PAY CODE		$ .
O	ENTER PAY CODE		$ .
	REMARKS: ENTER any PAY CODES listed in REMARKS		$ .
	TOTAL		$ .		Countable income after exclusions and annualizations =

POSSIBLE LUMP SUM PAYMENT:

“Did [NAME] receive this pay, [PAYCODE], once a year, monthly, or with some other frequency?”

• Once per year

• Quarterly

• Monthly

• OTHER: SPECIFY FREQUENCY OR PAY INTERVAL

IF FREQUENCY IS ONCE/YEAR OR QUARTERLY, THEN THE AMOUNT WILL BE ANNUALIZED. OTHERWISE ALL AMOUNTS ARE ASSUMED MONTHLY

POSSIBLE COMBAT PAY:

SELECT YES OR NO FOR EACH QUESTION

	YES	NO
Did [NAME] receive this pay in addition to the base pay?		
Was this pay the result of deployment to a designated combat zone?		
Did [NAME] only receive this pay while deployed to the combat zone?		

IF YES TO ALL THREE QUESTIONS, THE PAY WAS COMBAT PAY (AND WILL BE EXCLUDED FROM TOTAL INCOME)

IF NO, TO ANY QUESTION, THE PAY WAS NOT COMBAT PAY AND WILL BE INCLUDED AS INCOME.

Table 3. Military Pay Codes

Code	Type of Pay	Counts as Income unless noted otherwise
AB	Accession bonus	Ask Lump Sum
ACIP	Aviation Career Incentive Pay
ACP	Aviation Continuation Pay
AIP	Assignment Incentive Pay	Ask Combat Pay
ASP	Additional Special Pay
BAH	Basic Allowance for Housing	if State excludes
BAS	Basic Allowance for Subsistence
BAQ	Basic Allowance for Quarters	if State excludes
Base Pay	Base Pay
BCP	Board Certified Pay Special Pay
CCA	Civilian Clothing Allowance	Ask Lump Sum
BRA	Basic Replacement Allowance	Ask Lump Sum
Continuation Pay	Continuation Pay
CCCA	Continuing Civilian Clothing Allowance	Ask Lump Sum
CCRA	Cash Clothing Replacement Allowance	Ask Lump Sum
CEFIP	Career Enlisted Flyer Incentive Pay
CIP	Combat-related Injury & Rehabilitation	Ask Combat Pay
CMA	Clothing Maintenance Allowance or Clothing Allowance
CONUS COLA	Continental U.S. Cost of Living Allowance	Exclude, in-kind benefit
Combat Duty or Combat Zone Pay	Combat Duty or Combat Zone Pay	EXCLUDE
CRA	Clothing Replacement Allowance	Ask Lump Sum
CSP	Career Sea Pay
CSP-P	Career Sea Pay – Premium
CSRB	Critical Skills Retention Bonus	Ask Lump Sum
CVI	Conditional Voluntary Indefinite Status
DLA	Dislocation Allowance	Exclude, in-kind benefit
Dive Pay	Dive Pay	Ask Combat Pay
DSCT Meal	Discount Meal	Exclude, in-kind benefit
FDP	Foreign Duty Pay	Ask Combat Pay
FLPP	Foreign Language Proficiency Pay	Ask Combat Pay
Flight or Fly Pay	Flight or Fly Pay	Ask Combat Pay
FSA	Family Separation Allowance	Ask Combat Pay
FSH	Family Separation Housing	Exclude, in-kind benefit
FSSA	Family Subsistence Supplemental Allowance	EXCLUDE
HALO	High Altitude/Low Altitude	Ask Combat Pay
HDIP	Hazardous Duty Incentive Pay	Ask Combat Pay
HDP – Involuntary Extension	Hardship Duty Pay – Involuntary Extension	Ask Combat Pay
HDP – L	Hardship Duty Pay - Location	Ask Combat Pay
HDP – M	Hardship Duty Pay – Mission	Ask Combat Pay
HFP/IDP	Hostile Fire/Imminent Danger Pay	Ask Combat Pay
HFP-L	Hostile Fire Pay - Location	Ask Combat Pay
HZD	Hazardous Duty Pay	Ask Combat Pay
ICCA	Initial Civilian Clothing Allowance	Ask Lump Sum
IDP	Imminent Danger Pay Note: Can also mean Independent Duty Corpsman	Ask Combat Pay
ISP	Incentive Special Pay
Jump Pay	Jump Pay	Ask Combat Pay
LQA	Living Quarters Allowance	Exclude, in-kind benefit
Maternity Clothing Allowance	Maternity Clothing Allowance	Ask Lump Sum
MIHA – Miscellaneous	Moving Housing Allowance - Miscellaneous	Exclude, in-kind benefit
MIHA – Rent	Moving Housing Allowance – Rent	Exclude, in-kind benefit
MIHA – Security	Moving Housing Allowance - Security	Exclude, in-kind benefit
MRB	Multiyear Retention Bonus
MSP	Multiyear Special Pay
NIB	Nuclear Career Annual Incentive Bonus
NPAB	Nuclear Power Accession Bonus	Ask Lump Sum
Nuclear – Continuation Pay	Nuclear – Continuation Pay
OEP	Overseas Extension Pay
OHA	Overseas Housing Allowance	Exclude, in-kind benefit
OCONUS COLA	Overseas Continental United States Cost of Living Allowance	if State excludes
OTEIP	Army Overseas Tour Extension Incentive Pay
OVERSEAS COLA	Overseas Cost of Living Allowance	Exclude, in-kind benefit
Overseas Extension Pay	Overseas Extension Pay
PCCA	Partial Civilian Clothing Allowance	Ask Lump Sum
RBMA	Reserve Basic Maintenance Allowance
SBP	Military Survivor Benefits Plan
SAVE PAY	Save pay Note: This can represent many types of pay. Ask questions to determine what the pay is for to see if it counts. Often refers to difference in pay due to accepting a new appointment between new and old pay rates. Likely to be a lump sum.	Caution: ask if lump sum
SDAP	Special Duty Assignment Pay	Ask Combat Pay
SDIP	Submarine Duty Incentive Pay	Ask Combat Pay
Sea Pay	Sea Pay	Ask Combat Pay
SEA	Subsistence Expense Allowance
SEB	Selective Enlistment Bonus	Ask Lump Sum
SepRats	Separation Rations
SMA	Standard or Separate Maintenance Allowance
Special Duty Pay	Special Duty Pay	Ask Combat Pay
Specialty Pay	Specialty Pay	Ask Combat Pay
SPO	Split Payment Option Note: This option allows the person to take an amount from the base pay and put it into the ship ATM for personal use while on board. Base WIC income eligibility on the gross amount before the split allocation. Don’t count the amount sent to the ship account twice.	Caution
SR	Separation Rations
SRA	Standard Replacement Allowance	Ask Lump Sum
SRB	Selective Reenlistment Bonus	Ask Lump Sum
Standard Initial Clothing Allowance	Standard Initial Clothing Allowance	Ask Lump Sum
Submarine Pay	Submarine Pay
SUPP CMA	Enlisted Supplemental Clothing Allowance	Ask Lump Sum
TDYCCA	Temporary Duty Civilian Clothing Allowance	Ask Lump Sum
TLE CONUS	Temporary Lodging Expense in US	Exclude, in-kind benefit
TLA	Temporary Living Allowance	Exclude, in-kind benefit
TLA OCONUS	Temporary Lodging Allowance Outside US	Exclude, in-kind benefit
TQSA	Temporary Quarters Subsistence Allowance
VI	Voluntary Indefinite Status
VBSS Duty	Maritime Visit, Board, Search & Seizure Duty
VSP	Variable Special Pay

ZERO INCOME REPORTED [TOTAL INCOME=$0]

IF APPLICANT DID NOT CLAIM PARTICIPATION IN MEDICAID, SNAP AND/OR TANF; AND IF APPLICANT’S TOTAL FAMILY INCOME =$0; AND IF NO ADULT AGED ≥ 15 WAS REPORTED TO HAVE SEPARATE FINANCES, CAPI WILL DISPLAY INTRO AND Z2.

IF APPLICANT DID NOT CLAIM PARTICIPATION IN MEDICAID, SNAP AND/OR TANF; AND IF APPLICANT’S TOTAL FAMILY INCOME =$0; AND IF ANY ADULT AGED ≥ 15 WAS REPORTED TO HAVE SEPARATE FINANCES, CAPI WILL DISPLAY INTRO AND START WITH Z1.

INTRO: “If I understand your answers correctly, it looks like you had zero income on [APP_DATE].”

Z1. You said that [NAME] and [NAME] were not part of your family group. Was/Were [LIST NAMES WHERE Q6=SEPARATE FINANCES], or was anyone that you haven’t named helping you to pay for living expenses such as rent/mortgage, heat, or food on [APP_DATE]?

• Yes GO TO Z1a

• No GO TO Z2

Z1a. “In that case, I need to ask you about [NAME]’s income. Thinking back to the 30 days before [APP_DATE], did [NAME] have any income from [LIST EACH TYPE OF INCOME SOURCE FROM Q9A]? CAPI WILL PROMPT INTERVIEWER TO CHANGE THE RESPONSE TO Q6 FOR [NAME(S)] TO Q6=1 SO THAT THIS INDIVIDUAL IS COUNTED AS PART OF APPLICANT’S FAMILY.

AFTER Z1a GO TO END OF SURVEY

Z2. “I’d like to better understand how you were paying for living expenses in [MONTH, YEAR OF APP_DATE]. Can you tell me if any of the following were true: CHECK ALL THAT APPLY.

I had applied for public assistance but did not receive payment until after [MONTH, YEAR OF APP_DATE] (IF NECESSARY: such as Temporary Assistance to Needy Families, sometimes called welfare, or SNAP/Food Stamps).	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, PUBLIC ASSISTANCE
I had applied for workers compensation but did not received payment until after [MONTH, YEAR OF APP_DATE]	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, WORKER’S COMPENSATION
I received some emergency cash from a friend, church, or social services agency or food from a food bank	ENTER AMOUNT IN Q9, OTHER CASH
I skipped one or more rent, mortgage or utility payments
I did some work such as child care, housework, or another service in exchange for reduced rent or food	IN-KIND BENEFITS NOT INCOME
OTHER: “Can you describe how you paid for living expenses then?” TYPE IN RESPONSE: ____	IF ANY INCOME SOURCES RETURN TO Q9
NONE OF THE ABOVE

AFTER Z2 GO TO END OF SURVEY

INCOME PROBE QUESTIONS (POSSIBLE EXCLUSIONS OR LUMP SUMS)

AT ANY TIME WHILE ASKING APPLICANT ABOUT INCOME SOURCES (Q9), THE INTERVIEWER MAY BRING UP A LIST OF THE FOLLOWING POTENTIAL LUMP SUM OR INCOME EXCLUSION QUESTIONS:

If applicant is a member of an American Indian Tribe and:	ASK/DO
Reports income from the government or Tribe	“Did you receive this income as part of a settlement or agreement between the U.S. government and an American Indian tribe or Nation?” EXCLUDE ANY SUCH INCOME3 “Is this income a ‘per cap’ or per capita payment from a business operated by an American Indian tribe or Nation to which you belong?” ENTER NET AMOUNT UNDER ROYALTIES. ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED

If applicant or income document refers to:	ASK/DO
Section 8, housing voucher, rental assistance	“Is this a voucher to help you afford housing or rent?” ANY AMOUNT SHOWN ON A HOUSING CHOICE VOUCHER IS NOT COUNTED AS INCOME. DO NOT ENTER AS AN INCOME SOURCE.4
Child care or day care voucher, child care or day care assistance	EXCLUDE ANY REPORTED PUBLIC ASSISTANCE OR SUBSIDY FOR DAY CARE OR CHILD CARE COSTS5
Food Stamps, Free or Reduced Price Lunch or Breakfast for child in public school, WIC food instruments provided to other WIC participants in family	EXCLUDE ANY REPORTED PUBLIC ASSISTANCE WITH MEALS OR FOOD, INCLUDING ANY REPORT OF FREE MEALS A CHILD RECEIVES AT SCHOOL, FOOD INSTRUMENTS RECEIVED BY ANY FAMILY MEMBER FROM SNAP, FDPIR, OR WIC.6
Job assistance, employment training, Employment Services Program, Job Corps, Youth Build, job training, American Job Center, Workforce Investment, Employment Training, Career Pathway	“Was this income to reimburse you for transportation, child care costs or other expenses so that you could take part in job training, get a GED or take classes that will prepare you for employment?” EXCLUDE REIMBURSEMENTS FOR THESE EXPENSES 7
Volunteer, AmeriCorps, VISTA	“Was this income you received as a volunteer for AmeriCorps, AmeriCorps VISTA or AmeriCorps National Civilian Community Corps (NCCC)?”8
Bonus/commissions	ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED
Royalties	ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED
Any mention of emergency assistance due to a hurricane, tornado, storm, earthquake, volcano, landslide, mudslide, snowstorm, flood, forest fire	“Did you receive [this] assistance because of a major disaster such as a hurricane, tornado, storm or similar natural event that was declared a federal disaster?” FEMA maintains a list of federal disasters each year: https://www.fema.gov/disasters/grid/year/2015. EXCLUDE ANY ASSISTANCE DUE TO FEDERAL DISASTER FROM INCOME SOURCES9
Any mention of loss of property due to flood/hurricane	“Did this income come from FEMA or the National Flood Insurance Program after filing a claim for flood damage to your home? EXCLUDE ANY INCOME DUE TO APPROVED FLOOD DAMAGE CLAIM10
Veteran’s or VA payment, VA disability	“Did you/NAME receive payment because you were exposed to Agent Orange while serving in Vietnam or Korea?” EXCLUDE ANY AMOUNT DUE TO EXPOSURE TO AGENT ORANGE. INCLUDE ALL OTHER VETERAN’S PAYMENTS11
Loan, Student loan	“Is this income part of a loan that you must repay?” EXCLUDE ANY LOAN AMOUNT FROM INCOME SOURCES unless the loan is an amount to which the applicant has constant access (e.g., regular contributions from someone not in the household)12

END OF SURVEY

“Ok, this completes our survey. It was great talking with you, and thank you so much for helping us out. Here is a $25 Visa debit card in appreciation for your time.”

Field Interviewer confirmation at end of survey:

I met with study respondent at the following address on the date below: MAKE ANY CORRECTIONS IN THE ROW BELOW								INITIALS
State:	MN	City:	Anytown	ZIP	12345	Street	100 MAIN STREET
						Date	mm/dd/yy

• Location was a residential address

• Location was a non-residential address (e.g., library, business, community center). PROVIDE NAME OF LOCATION:

Privacy Act Statement

Authority: Code of Federal Regulations. §215.11 requires State and local WIC agency directors to cooperate in the conduct of studies and evaluations.  

Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration and evaluation of Special Supplemental Program for Women, Infants and Children.

Routine Use: FNS published a system of record notice (SORN) titled FNS-8 USDA/FNS Studies and Reports in the Federal Register on April 25, 1991, volume 56, pages 19078-19080, that discusses the terms of protections that will be provided to respondents.

Disclosure: Your participation in this survey is voluntary.

1 Although WIC policy guidance indicates that agencies should determine whether or not separate family economic units have “adequate income” to “sustain the economic unit” and that the “actual living and support costs for the economic unit in that environment must be considered,” the guidance does not indicate how agencies should determine these “actual living and support costs” or what threshold relative to these costs would suffice as “adequate.” Because these judgments are inherently subjective, the NSWP-III cannot independently confirm or disconfirm an independent judgment made by staff at a local WIC agency. If a Participant indicates that a resident of the household maintains separate finances, the NSWP-III will treat those persons as economic unit(s) separate from the participant’s economic unit.

2 See Table 3 for specific military pay codes and proposed exclusions. WIC regulations allow States to choose whether or not to exclude the military Basic Allowance for Housing (BAH) and Cost-of-living allowance for service members stationed outside the contiguous United States (OCONUS COLA) (See 246.7(2)(d)(iv)(A). WIC regulations require States to exclude from income payments to service members from the Family Supplemental Subsistence Act (FSSA) and combat pay. In the context of military pay, WIC Policy Memorandum 2013-3 indicated that “in-kind benefits, such as military on-base housing or other subsidized housing, medical and dental benefits are services that do not meet the definition of ‘income’ and may not be considered in income eligibility determinations.”

3 WIC regulations include income exclusions for multiple types of payments to members of American Indian Tribes from various treaties, agreements or settlements with the U.S. government (see 246.7(2)(d)(iv)(D)(4, 6, 7, 9, 10, 21, 24-32)).

4 WIC regulations include income exclusions for multiple forms of housing assistance to low income individuals (see 246.7(2)(d)(iv)(D)(1, 22-23)

5 WIC regulations include income exclusions for payments, or the value of, child care under the Social Security Act or the Child Care and Development Block Grant programs (see 246.7(2)(d)(iv)(D)(17-19)

6 WIC regulations include income exclusions for the value of food assistance from the National School Lunch Program, the Child Nutrition Act or the Food and Nutrition Act (see 246.7(2)(d)(iv)(D)(8).

7 WIC regulations include income exclusions for payments under the Job Training Partnership Act, replaced by the Workforce Investment Act (WIA) and Workforce Investment and Opportunity Act (WIOA). See 246.7(2)(d)(iv)(D)(5).

8 WIC regulations exclude payments to domestic volunteers (VISTA is now part of AmeriCorps). See 246.7(2)(d)(iv)(D)(2)

9 WIC regulations exclude income from assistance received under the Disaster Relief and Emergency Assistance Amendments of 1989, now the Robert T. Stafford Disaster Relief and Emergency Assistance Act. See 246.7(2)(d)(iv)(D)(13)

10 WIC regulations exclude income from assistance to property owners under the National Flood Insurance Program (246.7(2)(d)(iv)(D)(34).

11 WIC regulations exclude income to certain veterans from the Agent Orange Compensation Exclusion Act ((246.7(2)(d)(iv)(D)(15))

12 WIC regulations exclude loans (246.7(2)(d)(iv)(C)).

pg. 1