Office of Nutrition Services
350 Capitol Street • Room 519 • Charleston, WV 25301-3715
phone: 304-558-0030 • fax: 304-558-1541

Vendor Forms

The following forms are available to prospective and current West Virginia WIC Vendors. All of the forms are fillable PDF forms, which should be completed, signed and returned to the Vendor Management Unit at:

Office of Nutrition Services, West Virginia WIC Program
Vendor Management Unit
350 Capitol Street, Room 519
Charleston, WV 25301-3715
phone:  304-558-1115
fax:  304-558-1541
dhhrwicvu@wv.gov

Vendor Authorization Application & VPL
This form is the West Virginia WIC Vendor Authorization application. Please complete all section of the application, following the directions. Incomplete applications will be returned for completion.

Authorization Agreement for Direct Deposit
The West Virginia WIC Program no longer issues replacement checks for drafts submitted to the State WIC Office for payment. Instead, reimbursement for these draft is deposted directly into the vendor's account. To setup direct deposit please complete all sections of this form, sign, attach a voided check and return to the West Virginia WIC Vendor Unit.

Vendor Price List
This form is required of all authorized and applicant grocery vendors and is the official record of your shelf prices. 

Request for Reimbursement
To request reimbursement for drafts, please complete this form indicating how the problem occured and the corrective action needed to eliminate the problem. Vendors may use one request for for several drafts if hte problem indicated by the rejection code is the same.

Sanction Point Status
To request your WIC saction point status, please complete this form, sign and return to the West Virginia WIC Vendor Unit. Your status will be sent to the attention of the person indicated on the form. 

Complaint Form
To file a complaint against a vendor, please complete this form, sign and return to the West Virginia WIC Vendor Unit. Participant and Local Agency complaints should be returned to:

Office of Nutrition Services, West Virginia WIC Program
350 Capitol Street, Room 519
Charleston, WV 25301-3715
phone:  304-558-0030
fax:  304-558-1541
dhhrwicvu@wv.gov

Appeals Request
To appeal a disqualification/sanction letter, please complete, sign and return this form to the West Virginia WIC Vendor Unit. Any previously assessed sanctions which the vendor elected not to challenge, or challanged but then abandoned or the agency action was upheld via the apeals process will not be considered at this or any further administrative appeals procedure, disqualification from the West Virginia WIC program which is a result of disqualification from teh Food Stamp Program is not subject to administrative or judicial appeal under the West Virginia WIC Program. State agency determination as to what constitutes inadequate particpant access is not subject to administrative appeal.

Resignation Form
Please complete, sign and return this form to the West Virginia WIC Program if you intend on terminating your participation as an active vendor.

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