4875 (pdf)
State of Illinois
Department of Human Services
Illinois WIC Authorized Product List UPC Submission Form
If a food item is not scanning as a WIC approved item a request can be submitted to have the product reviewed. To submit a product, complete the information below or for multiple items complete the IL WIC UPC Request Spreadsheet. All submissions must be for a product that is currently approved on the Illinois WIC Authorized Food List and include photos that clearly show the Nutrition Facts, including ingredients, size, UPC, product name and brand. UPC, product name and brand. Submit completed forms and photos to DHS.WICFoods@illinois.gov
Contact Information
First Name__________________________ Last Name_____________________
Company Name (optional)____________________________________________
Email Address____________________________Phone Number______________
Today's Date_________________
Product Information
|
UPC Number
(12-13 digits)
|
Brand Name
of Product
|
Food
Description
|
Container Size
(in ounces)
|
Additional
Comments
|
|
UPC Number
(12-13 digits)
|
Brand Name of
Product
|
Food
Description
|
Container Size
(in ounces)
|
Additional
Comments
|
This Section to be Completed by State WIC Staff Only:
UPC Request APPROVED UPC Request DENIED
Reason Request Denied_________________________________________________
Approved By_________________________________ Date_____________________
IDHS 4875 (N-01-20) IL WIC Authorized Product List - UPC Submission Form Web
