Client Complaint Form

Date Problem Occured

Time Problem Occured

Store Name and Number

Store Address or Location

Clients Name

Clients Identification Number

Check Numbers Involved (if available)

Describe problem at the store
The client attempted to do the following:
 Use a pre-signed check Use an altered check Request cash or credit for WIC check or WIC foods purchase unauthorized food(s) with WIC check Purchase non-food items with a WIC check Use check before FIRST DATE OF USE Use check after LAST DATE OF USE Behaved inappropriately in the store Other

Describe as much detail as possible in the box below about your problem

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 Coordinator.