2. After completing pages 2 through 8, sign below to certify the accuracy of this report.

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1 ITCA WIC ENROLLMENT VENDOR PRICE/STOCK SURVEY FY INSTRUCTIONS Complete all sections of pages 1 through 11, documenting the price and quantity of each WIC food item currently on the shelf or in inventory housed at your store location. If a space is left blank, the WIC program will assume that your store does not have that particular food item. Do not estimate or project prices or stock. The enrollment Vendor /Stock Survey must reflect actual shelf prices and actual stock on hand at the time of completion. 1. On pages 2 through 8, answer all yes and no questions and list the highest actual shelf price for each WIC food item in stock. Fill in the price for the exact size listed. NOTE: you must carry both milk and soy based iron fortified infant formula. Low iron formula may not be counted in the quantity listed. 2. After completing pages 2 through 8, sign below to certify the accuracy of this report. 3. If you would like a copy of this survey, please copy before you submit the survey to ITCA. CERTIFICATION I certify that: i. I am authorized to act on behalf of the Vendor. ii. I have verified that the required amounts of WIC inventory described on pages 2 through 8 are either on the shelves or in an inventory housed at the Vendor s store location. iii. I have verified the prices listed on pages 2 through 8, are true and correct. Signature Print Name ( ) Telephone Number Date Title ( ) Fax Number Page 1 of 8

2 Instructions: List the highest regular, NOT sale, price for each WIC food item in stock. YOGURT- These brands only, in 32 ounce containers Quantity: Are there at least 4 (32) containers? No, If NO, # of containers in stock Variety: Does the vendor carry 2 varieties and at least 1 container whole milk yogurt AND 3 containers 1% or non-fat yogurt? No, If NO, # of varieties in stock Brown Cow Dannon LALA Mountain High Yoplait Essential Everyday Food Club Great Value Kroger Market Pantry Lucerne MILK-Store / House : Is the mandatory shelf label posted? No Quantity: Are there at least 12- gallons and 3 half-gallons of refrigerated milk? No, If NO, # in stock: Gallons Half-Gallons Variety: Does the Vendor carry 3 gallons of Whole milk AND 9 gallons 1% or skim milk? and 3 gallons of 1% or Skim milk? MILK ALTERNATIVES Item Type/Size Tofu 8 th Continent Soy Milk Pacific Ultra Soy Silk any eligible brand (up to 16 ) refrigerated, original or vanilla, ½ gallon only shelf stable, original or vanilla, quart only (32 ) refrigerated, original, ½ gallon only No, If NO, Variety missing EGGS Store / House : Type Gallon ½ Gallon Quart Whole Reduced Fat (2%) Low Fat (1%) Fat Free (Skim/ Nonfat) Lactose Reduced Evaporated Whole 12 can Evaporated Skim 12 can Non Fat Dry 25.6 Whole Dry 25.6 Is the mandatory shelf label posted? No Type Medium and / or large, fresh, raw, white, chicken only (1 dozen cartons) Quantity: Are there at least 4 dozen eggs? No, If NO, # of dozen containers in stock Size - 1 dozen Large Medium Refrigerator Temperature: F (Acceptable: 45 ) Refrigerator Temperature: F (Acceptable: 45 ) Page 2 of 8

3 CHEESE Store / House : Is the mandatory shelf label posted? No Type- Plain, domestic, pasteurized 16 prepackaged in blocks Quantity: Are there at least 4 pounds? No, If NO, # of pounds in stock Variety: Are there at least 2 varieties? No, If NO, # of varieties in stock Type 1 pound ( 16 ounce ) Cheddar (includes longhorn) Colby (includes longhorn) Monterey Jack Mozzarella (whole or part skim) Mozzarella string cheese (whole of part skim) Blended cheese (blend of any type listed above) Refrigerator Temperature: F (Acceptable: 45 ) CEREAL Boxes or Bags Quantity: Are there at least 14 packages (12 cold and 2 hot)? No, If NO, # of varieties in stock Cold Hot Variety: Are there at least 3 varieties of cold cereal and 1 hot cereal? Variety: Are at least half of cold cereals whole grain? (*indicates whole grain) No, If NO, # of varieties in stock Yes No, variety missing COLD CEREALS (14 or larger) Best Yet Crispy Rice SIZE PRICE SIZE PRICE SIZE PRICE First Street Crispy RIce Great Value Crispy Rice Best Yet Toasted Oats Essential Everyday Toasted Oats First Street Toasted Oats Food Club Toasted Oats Great Value Toasted Oats Hy-Top Toasted Oats Kroger Toasted Oats Market Pantry Toasted Oats Safeway Kitchens Toasted Oats General Mills Cheerios - Plain* Page 3 of 8

4 General Mills Cheerios MultiGrain* General Mills Corn Chex General Mills Wheat Chex* General Mills Rice Chex General Mills Kix Plain General Mills Total Whole Grain* Kellogg s All Bran Complete Wheat Flakes* Kellogg s Corn Flakes Kellogg s Rice Krispies Kellogg s Frosted Mini Wheats Original* Kellogg s Special K Original Malt O Meal Frosted Mini Spooners Malt O Meal Crispy Rice Post Great Grains Banana Nut Crunch Post Honey Bunches of Oats Almonds Post Honey Bunches of Oats Honey Roasted Post Honey Bunches of Oats with Vanilla Bunches* Post Grape Nuts* Post Grape Nuts Flakes Quaker Life Original* Quaker Oatmeal Squares Brown Sugar* Quaker Oatmeal Squares Cinnamon* HOT CEREALS (11.8 or larger) Cream of Wheat Instant Original Flavor (single serving packets) SIZE. PRICE SIZE. PRICE SIZE. PRICE 12 Malt O Meal Original Hot Wheat Cereal Quaker Instant Oatmeal Original Flavor (single serving packets)* Page 4 of 8

5 WHOLE GRAINS 100% WHOLE WHEAT BREAD Loaves only, 16 ounce packages (includes any store brand labeled 100% whole wheat) Quantity: Are there at least 6 packages (16 each)? No, If NO, # of packages in stock Only these brands Bimbo 100% Whole Wheat Roman Meal Sun Grain 100% Whole Wheat Sara Lee Classic 100% Whole Wheat Nature s own 100% Whole Wheat Bread Wonder 100% Whole Wheat Oroweat 100% Whole Wheat Bread Ozark Hearth 100% Whole Wheat Bread Store brand: (must be labeled 100% Whole Wheat) TORTILLAS, PASTA AND BROWN RICE Quantity: No requirement. Soft Corn Tortillas Only these brands of yellow or white Carlita Casa Rica Don Pancho Guerrero La Banderita La Burrita Mama Lola s Mission Santa Fe Tortilla Company Soft Whole Wheat Flour Tortillas Only these brands: Carlita Guerrero Tortillas de Harina Integral La Banderita Fajita Mission IGA Sunrise Bakery Whole Wheat Pasta 16 packages only Quantity: Are there at least 4 (16 ) packages? No, If NO, # of packages in stock Only these brands (16 ) (16 ) DeLallo Hodgson Mill Page 5 of 8

6 Brown Rice only these brands of long or short grain Blue Ribbon Springfield Mahatma Store / House : Shurfine Store / House : LEGUMES Dry Beans / Peas / Lentils Quantity: Are there at least 4 (1lb) packages? No, If NO, # of packages in stock Variety: Are there at least 2 varieties? CANNED FISH Tuna Any eligible brand, plain, chunk light, water-packed. Are there at least: 6 (5) cans? No, If NO, # of cans in stock Pink Salmon - Any eligible brand, plain, water packed pink salmon. Are there at least: 6 (5oz) cans? No, If NO, # of varieties in stock No, If NO, # of cans in stock Item Beans 1 lb. package Sardines Any eligible brand, flavored, seasoned or plain. Are there at least 8 (3.75 ) cans? Peas / Lentils No, If NO, # of cans in stock Canned Beans Any eligible brand (up to 16 cans) Quantity: Are there at least 8 cans (up to 16 size) Type Size No, If NO, # of cans in stock Tuna 5 Variety: Are there at least: 2 varieties (1 must be pinto beans)? No If NO, variety missing Type Size Pinto Black Pink Salmon 5 Sardines 5 PEANUT BUTTER Any eligible brand, plain (creamy, chunky, super chunk or natural) Are there at least 2 jars of peanut butter? Garbanzo Cannellini No, If NO, # of jars in stock White Kidney Size (16 to 18 ) Great Northern Red Kidney Black-eyed peas Navy Red Pink Lima Page 6 of 8

7 JUICE Vitamin C Fortified 100% juice, no added sugar Quantity: Are there at least 4 shelf stable / refrigerated and 6 frozen containers? FRESH FRUITS and VEGETABLES Any variety of fresh Quantity: Are there at least 15 pounds of fresh vegetables (excluding potatoes)? No, If NO, # of containers in stock No, If NO, # of pounds of fruits in stock Variety: Are there at least: 3 varieties of shelf stable or refrigerated (must include orange juice) and 2 varieties of frozen concentrate? No, If NO, # of varieties in stock Item 64 Refrigerated 64 Shelf Stable Any Orange Any Grapefruit Campbell s Tomato Dole Pineapple Dole Pineapple Orange Langer s Apple Langer s Grape Langer s White Grape Langer s Pineapple Old Orchard Apple Old Orchard Grape Old Orchard Pineapple 11.5/12 frozen and # of pounds of vegetables in stock Variety: Are there at least 3 varieties of fruit and 5 varieties of vegetables? No, If NO, # of varieties of fruits in stock INFANT BANANAS Quantity: Are there at least: 16 bananas? # of varieties of vegetables in stock No, If NO, # of bananas in stock Document the Quality and Condition of Fruits and Vegetables (Provide type of items and brief description such as : excellent, good, spoiled, discolored, rotten, etc. Photographs must also be taken to support deficiencies). INFANT FRUITS / VEGETABLES Any of the following single or mixed variety of Stage 2, 4 infant fruits and vegetables Quantity: Are there at least 128 (4) containers (can be a combination of single and double packs)? No If NO, # of containers in stock (4oz) (4oz)2-pack Variety: Are there at least 4 varieties of vegetables? Seneca Apple No, If NO, # of varieties in stock Shurfine Apple Shurfine Grape Tree Top Apple Welch s Grape Welch s White Grape Western Family Apple Western Family Grape Freezer Temperature: F (Acceptable: 0 ) BeechNut Gerber 4 Single Tippy Toes 4 2-pack Page 7 of 8

8 INFANT JARRED MEAT Any of the following brands, any stage, single ingredient with or without added broth or gravy. Quantity: Are there at least 31 (2.5) containers? INFANT CEREAL- Gerber and/or BeechNut, single grain, without Fruit (only these varieties: barley, oatmeal, rice, whole wheat) Quantity: Are there at least 12 (8) boxes? No, If NO, # of containers in stock No Variety: Are there at least 2 varieties? If NO, # of boxes in stock No, If NO, # of varieties in stock Variety: Are there at least 2 varieties? (must include rice) 2.5 BeechNut Gerber Tippy Toes INFANT FORMULA - Iron Fortified, NO LOW IRON Yes No If NO, # of varieties in stock does not carry rice 8 MILK BASED FORMULA (Similac Advance) Are there at least 27 cans powder? No, If NO, # cans in stock SOY- BASED FORMULA (Enfamil ProSobee) Are there at least 9 cans powder? No, If NO, # cans in stock CONTRACT FORMULA Powder size (up to 16 ) Powder Concentrate (13 ) RFT (Quart/32 ) Similac Advance Enfamil ProSobee RFT -8 (4 or 6 pack) Other Formula Similac Total Comfort Similac Sensitive Similac Expert Care Alimentum Similac Expert Care Neosure Similac Pediasure Similac Pediasure with Fiber Similac Go & Grow Similac Sensitive for Spit-up EleCare for Infants Enfamil EnfaCare Enfamil Toddler Transitions Soy Nutramigen (with or without Enflora) Pregestimil Gerber Good Start Nourish Page 8 of 8