Providers must use the WIC Summary Expenditure Documentation Form (EDF) to provide reporting of expenditures.  WIC providers are required to break out expenditures into the categories of Administration, Breastfeeding, Client Services and Nutrition Education.  These categories are included as headings under Components in the WIC EDF.

WIC EDF 444-4293

Form Features:

  • Fillable PDF form
  • Enabled to save data entered prior to submission
  • Auto Calculation:
    • AMOUNT CLAIMED column: totals amounts in the Title/Purpose row based on the amounts entered in the four components
    • TOTAL: totals amounts in all columns (AMOUNT CLAIMED, Administration, Breastfeeding, Client Services, Nutrition Education)

Helpful Instructions

  • Person Completing Form - Name of Contact person. (Mandatory)
  • Phone - List the phone number and extension for a contact person who will be able to answer questions concerning the submitted expenditure form. (Mandatory)
  • Email Address - Provide the email address of the contact person who will be able to answer questions concerning the submitted expenditure form. (Mandatory)
  • Date Submitted - Submittal date of the EDF.
  • Agency Name - Name of the Agency.
  • FEIN - Provide the Agency's Federal Employee Identification Number (FEIN). (Mandatory)
  • Contract and Document Number - List your DHS contract number and document number.
  • Program Name - Provide the name of the program being reported on.
  • Cumulative Amount (Year to Date) - Enter the cumulative dollar amount, Year to Date. (Mandatory)
  • Reporting Period - Month (mm) & Year (YYYY)
  • Check Box - Indicate whether or not the submitted EDF is a 'Revised Report,' if it is place either a check or X in the box.
  • Personal Services/Fringes - All provider agency staff whose salary and/or fringe benefits are paid in full or in part from grant funds for this program (fringe benefits are the employer's portion of fringe benefits actually paid on behalf of direct services employees).
  • Contractual Services - This category includes such items as contractual employees or consultants, utilities, rent or lease of equipment, space or facilities, postage, repair and maintenance of furniture and equipment, software for support of program objectives, training and education costs, conference fees, membership dues/fees (agency memberships only), subscriptions.
  • Travel - This category includes mileage, parking, per diem, meals, lodging and other associated travel items.
  • Supplies - This category includes such items as office supplies, medical supplies, educational and instructional material and supplies, cleaning supplies, equipment items costing less than $100 each, printing.
  • Equipment - Equipment costing $100 or over per item. Prior approval is necessary for equipment items costing $500 or above and having a useful life of more than one year (written approval must be given by Department program staff).
  • Other - Other allowable costs. Refer to Program Manual.
  • MATCH (IF REQUIRED) - Match is not used in the WIC program.
  • TOTAL - Enter the total amount of claimed expenditures.
  • Components - Administration, Breastfeeding, Client Services and Nutrition Education (Mandatory) 
  • Authorized Agency Official - This form must be signed by an authorized official of the provider agency. (Mandatory)