Vendor Complaint Form

Date Problem Happened at Store

Time Problem Happened at Store

Store Name and Number

Store Address or location

Name or description of store cashier or staff person involved

Describe problem at the store
 Store was out of approved foods Foods were expired or of poor quality Store would not accept my eWIC card Store did not allow me to buy authorized foods Store required me to buy all my foods Other

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

Your Name (optional)

Local Agency where you receive services

Phone number or email address (optional)