216-RICR-20-05-3. WIC Program (version Amendment, 02/17/2002 to 02/26/2003)

RHODE ISLAND WIC PRICE SHEET (WIC-34) GROCERY WIC STAMP PHARMACY WIC STAMP _____________ VENDOR # _____________ TODAYS DATE STORE NAME STORE ADDRESS HOW TO FILL OUT THIS FORM Your Vendor Application or Reapplication Agreement will not be processed if this WIC Price Sheet is not properly completed and returned with the package. Remember that charges for WIC Food must be competitive. Fill in your current selling price on pages 2 - 8 for all foods on the Price Sheet available in your store at this time. If an item has more than one price, (MEANING: you have more than one brand of the same item) enter the lowest and the highest price. If you have only one item price, enter that price in the "High" column. If you also have a special price for WIC, enter that price on the column that says "WIC SPECIAL PRICE". The Boxes at the top of Pages 1, 3 & 5 must be stamped with your WIC Vendor/Pharmacy stamp(s). You must complete the store identification information on the beginning of this form. An authorized store representative must sign and date this form. Submission of this price sheet does not mean that the WIC Program accepts or approves any or all of your price(s). Si necesita ayuda en comprender este formulario, por favor, llame al 222-4621 donde le ayudaràn con la traducciòn. 5/22/01 1 Rev. 4/01 MILK JUICE Milk SIZE Price High Low WIC Special Price Juice SIZE Price High Low WIC Special Price Total 512 oz. of Whole, Skim, and/or Low Fat (at least 3 gal., 2-1/2 gal., & 2-1/4 each) Total of 2 types (12-46oz. + 12-16Frozen.) 12 oz. Fz. Carnation 12 oz. 12 oz. Fz. Pet 12 oz. 12 oz. Fz. 1 lb. 12 oz. Fz. Other 12 oz. Fz. 1 quart ½ gal. 1 quart Apple Frozen IGA Seneca (Red can) Shaw’s Stop & Shop Others 1/2 gal. 46 oz. can Gallon Grapefruit 100% 12 oz. frozen Evap. Powder Lactaid Skim And/or Low Fat 46 oz. cans Juicy Juice Brand All flavors 11.5 conc. Quart 1/2 gal. Gallon 46 oz. cans 12 oz. Fz. Whole oz. Fz. Brown White Size Medium Orange 100% cans and/or frozen Other Large 1 doz. 12 oz. 1 1/2 doz. 46 oz. X-tra Large Jumbo 46 oz. 12 oz. Pineapple 100% Vit. C Delmonte Dole 46 oz. 12 oz. Fz 12 oz. Fz. 12 oz. Fz. 11.5 oz.. Eggs (5 doz. Large) Grape Welch’s White Welch’s Purple S & S Purple Seneca Purple 2 CHEESE CHEESE Quantity Price High Low WIC Special Price CHEESE Price High Low WIC Special Price 12 oz. or more 3 # each of 2 types 12 oz. or more 3 # each of 2 types oz. 12 oz. 12 oz. 16 oz. Pkg. 16 oz. Pkg. 16 oz. Deli 16 oz. Deli American 12 oz. Shred. oz. Other 16 oz. Shred oz. 16 oz. Pkg. 16 oz. Deli 12 oz. Shred Cheddar 16 oz. Shred oz. oz. Colby 12/16 oz. Shred. oz. 16 oz. Pkg. 16 oz. Deli 12/16 oz. Shred Monterey Jack oz. oz. 12 oz. 16 oz. Pkg. 16 oz. Deli 12 oz. Shred. Mozzarella 16 oz. Shred. oz. 16 oz. Pkg. 16 oz. Deli Muenster 12/16 oz. Shred. oz. 16 oz. Pkg. 16 oz. Deli Provolone 12/16 oz. Shred. 3 Affix your WIC STAMP CEREALS 36 oz. Each of each of 4 brands. One must be a 18 oz. Box SIZE Price High Low WIC Special Food 36 oz. Each of 4 brands. One must be a 18 oz. Box (Continued) SIZE Price High Low WIC Special Food Banana Nut Crunch Post 15.5 oz. 12 oz. 16 oz. 18 oz. Bran Flakes Post 20 oz. Total, Whole Grain General Mills 15 oz. Wheatena International Foods 22 oz. 20 oz. 12 oz. Cheerios General Mills 30 oz. 18 oz. 12 oz. Wheaties General Mills 24 oz. 18 oz. Corn Flakes Kelloggs 24 oz. 12 oz. Country Corn Flakes General Mills 15 oz. 14 oz. Cream of Wheat Nabisco 28 oz. 14 oz. Farina Farina 28 oz. 16 oz. Grape Nuts Post 24 oz. 13 oz. KIX General Mills oz. 15.5 oz. 16 oz. 21 oz. Life Regular Quaker 14 oz. Oatmeal Maypo Vermont Style 19 oz. 16 oz. 20.4 oz. 19 oz. 24.3 oz. 16.5 oz. Mini-Wheats Kelloggs Frosted Originals Frosted Bite Size Raisin Strawberry 16.5 oz. 16 oz. Toasted Oatmeal Squares Quaker 26 oz. 4 PRIVATE LABEL CEREALS BRAND NAME SIZE Price High Low WIC Special Food BRAND NAME SIZE Price High Low WIC Special Food 12 oz. 15 oz. Square Shaped Corn Cereal 17.5 oz. Tasteeos 35 oz. 12 oz. 12 oz. Square Shaped Rice Cereal 17.5 oz. Bite Size Corn 17.5 oz. 24 oz. 12 oz. Nutty Nuggets Bran Flakes 17.3 oz. Bite Size Rice 17.5 oz. Corn Flakes 18 oz. Corn Puffs 13 oz. IGA Toasted Oats 15 oz. 12 oz. Toasted Oats 15 oz. 18 oz. 18 oz. Corn Flakes 24 oz. Corn Flakes 24 oz. Crispy Hexagons 12.3 oz. Krunchy Nutties 24 oz. Nutty Nuggets 24 oz. Red & White Crisp Rice 13 oz. 13.5 oz. 15 oz. Stop & Shop Crispy Rice 15 oz. Toasted Oats 20 oz. Corn Puffs 13 oz. 12 oz. Crispy Corn Puffs 13 oz. Corn Greats 17.5 oz. Toasted Oats 15 oz. Rice Greats 12 oz. Sweet Life Crispy Corn & Rice 12.3 oz. 12 oz. Toasted Oats 15 oz. 18 oz. Corn Flakes 18 oz. Corn Flakes 24 oz. White Rose Crisp Rice 13 oz. Crispy Combos 12.3 oz. Nutty Nuggets 24 ox. 13.5 oz. Crispy Rice 15 oz. Shaw Wheat Flakes 18 oz. 5 Affix your WIC STAMP FORMULA INFANT CEREAL SPECIAL FORMULAS *2-1 lb. Can of 2 types and 24 8 oz. cans RTF Special Formula SIZE Price High Low WIC Special Price INFANT FORMULA(CONT.) *48 cans Enfamil and 39 cans ProSobee (Cont) 36 cans Enfamil + 24 cans ProSobee SIZE Price High Low WIC Special Price Alimentum 32 oz. RTF 13 oz. Conc. 8 oz. RTF(6 pk) Good Start(Carnation) 32 oz. RTF Ensure 32 oz. RTF 13 oz. Conc. 8 oz. RTF(6 pk) 32 oz. RTF Ensure Plus 32 oz. RTF Isomil 14 oz. Pd. 8 oz. RTF(6 pk) 32 oz. Conc. Ensure with Fiber 32 oz. RTF Isomil DF oz. RTF 32 oz. Conc. 13 oz. RTF 16 oz. Powder Isomil SF oz. Pd. *Nutramagen 1 lb. Powder 13 oz. Conc. *Pregestemil 1 lb. Powder 32 oz. RTF **Pediasure 8 oz. RTF(6 pk) Lactos Free (Enfamil) 14 oz. Pd. **Pediasure w/fiber 8 oz. RTF(6 pk) Neosure (Similac 14.1 oz. Pd. **Kindercal 8 oz. RTF(6pk) 13 oz. Conc. Isocal 32 oz. RTF 32 oz. RTF Osmolite 32 oz. RTF *ProSobee 14 oz.Pd. Sustacal 8 oz. RTF 13 oz. Conc. Sustagen 5 pound cans 32 oz. RTF Other Similac w/Iron 14.1 oz. Pd. 13 oz. Conc. INFANT FORMULAS 13 oz. Conc *48 Cans Enfamil and 39 cans ProSobee 36 cans Enfamil + 24 cans ProSobee 32 oz. RTF 13 oz. Conc. Similac Lactose Free 14 oz. Pd. 32 oz. Pd. 13 oz. Conc. Alsoy (Carnation) 14 oz. Pd. 32 oz. RTF 14 oz. Pd. Other 16 oz. Pd. Enfacare (Enfamil) oz. 13 oz. Conc. 32 oz. RTF 16 oz. Pd. INFANT CEREAL Total of 48oz. Dry (No Fruit) Must include 8oz. Box *Enfamil 2 # Pd. Size Enfamil 22 14 oz. Pd. 8 oz. Box Enfamil AR 14 oz. Pd. 16 oz. Box 13 oz. Conc. 32 oz. RTF Follow-up(Carnation) 12 oz. Pd. 6 Infant Formula Infant Cereal NOTE PHARMACIES MUST HAVE ANY FORMULA PRINTED ON THE FACE OF A CHECK WITHIN 48 HOURS OF THE REQUEST 7 PEANUT BUTTER (5 Containers) SIZE Price High Low WIC Special Price DRIED BEANS OR PEAS (2 # of 2 types) SIZE Price High Low WIC Special Price Jiff 18 oz. Black Beans 1 lb. Peter Pan 18 oz. Black Eyed Peas 1 lb. Reese’s 18 oz. California 1 lb. Skippys 18 oz. Chick Peas 1 lb. Smuckers 16 oz. Cow 1 lb. Store brand 18 oz. Fava 1 lb. Teddie 16 oz. Great Northern 1 lb. Generic 18 oz. Kidney 1 lb. Other 18 oz. Lentils 1 lb. Lima (Baby) 1 lb. Lima (Large) 1 lb. Mung 1 lb. Navy Beans 1 lb. Pigeon Beans 1 lb. Pink Beans 1 lb. Pinto Beans 1 lb. Red Beans 1 lb. (lowest price) 16 oz. Bags Roman 1 lb. Small White 1 lb. CARROTS 14 - 16 oz. caned or sliced Soy 1 lb. (lowest price) Split Peas (Green) 1 lb. SIZE Split Peas (Yellow) 1 lb. 6-6 1/2 oz. Cans Yellow-Eyed Beans 1 lb. Whole Peas Other TUNA FISH Light Chunk Style (Water or Oil) BRAND I certify that the information about this store’s prices and inventory is correct. Signature of Authorized Agent Print Name Date Title Submission of a price list does not mean that the WIC Program accepts or approves any and/or all of your price(s). One purpose of this Price Sheet is to collect price information. Some items listed are not WIC Allowed Foods. Ven-34-store listing price 8 Rev. 5/22/01 Peanut Butter Tuna Fish