Client Complaint Form

Date Problem Occurred

Time Problem Occurred

Store Name and Number

Store Address or Location

Clients Name (optional)

Clients Description or Last 4 Digits of Card Number

Describe problem at the store, please select from the following drop-down menu:

The client attempted to do the following: (may select multiple

Describe your concern in as much detail as possible in the box below:

The store requests the client receives more education about shopping with eWIC benefits.

Your Name (optional)

Phone number or email address (optional)

Information on this form is confidential. If you have any questions,
Please call (602) 258-4822 and ask for the Vendor Manager.