WIC Participant Fraud Reporting Form

Name of WIC Participant

(First)

(Last)

WIC Participant ID

(if available)

WIC Participant’s Gender

Male

Female

List all WIC Participants in the Family

(Please list names and WIC participant ID Numbers (if available))

WIC Participant Address

(if available)

City

State

Zip Code

WIC Participant Telephone Number

(Please enter the phone number in XXX-XXX-XXXX format.)

In the box below, please provide a description of the suspected WIC participant fraud. Be sure to include the important details such as names of persons involved and dates if available. If you are reporting suspected fraud based on an on-line posting, send a copy of the posting to WICfraud@la.gov.

Suspected Fraud Details

You are able to report suspected WIC Participant fraud anonymously, but if you would like the WIC State Agency to contact you, please complete the fields below:

Name

Telephone Number

E-Mail Address

Accessibility