Block 1: Enter the organization name and address (local agency).
Block 2: Enter the WIC local agency number.
Block 3: Has been completed for you.
Block 4: Has been completed for you.
Thru 9: Enter the dollar amount expended during the report month for each one of the four functional categories of NSA expenditures including indirect costs applicable for each category. Include all special funding (Peer Counseling, Registered Dietician Consultants, Lactation, Vendor Liaison, Dietetic Internship, etc.) Attached are more detailed explanations of cost categories.
General Administration: Expenditures generally considered being overhead or management costs.
Nutrition Education: Expenditures for general nutrition education. Do not include breastfeeding expenditures.
Breastfeeding: Expenditures for breastfeeding promotion and support.
Client Services: Expenditures for certification, food delivery and other client services and benefits.
Total: Add blocks 5-8.
Block 10: The original signature (no rubber stamps allowed) of the designated official (Local Agency).
Block 11: Print or type the name and title of designated official.
Block 12: Enter the date the report is submitted to the State Agency.
Block 13: Enter the telephone number of designated official.