TITLE 77: PUBLIC HEALTH
CHAPTER X: DEPARTMENT OF HUMAN SERVICES
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 672 WIC VENDOR MANAGEMENT CODE
SECTION 672.205 APPLICATION PROCEDURES


 

Section 672.205  Application Procedures

 

The Department shall provide an Application for applying to become an authorized WIC Retail Vendor.  Submission of a completed Application shall not constitute Authorization to an Applicant to accept or receive payment for Food Instruments.  Any Application submitted improperly or incompletely shall be returned to the Applicant.  Any Application not completed and returned to the Department within 90 calendar days from receipt by the Applicant shall not be processed.  An Applicant can apply for Authorization to become a WIC Retail Vendor by submitting the following to the Department:

 

a)         An Application for WIC Vendor Authorization as a sole proprietorship shall include the following:

 

1)         identity, address, and date of birth of owner;

 

2)         the Federal Employer Identification Number (FEIN) of the Business Entity;

 

3)         identification of any ownership interest of 30% or more in any other entity applying for WIC Vendor Authorization or WIC Vendor;

 

4)         identification of the Business Entity, the Store Type, location of the proposed Vendor Site and an employee contact for WIC purposes;

 

5)         proof of the owner's identity;

 

6)         proof of the Business Entity's FEIN;

 

7)         proof of USDA Food Stamp Authorization, if applicable; and

 

8)         identification of any person holding elective office as specified in Section 672.210(a)(7) and Section 11.1 of the Illinois Purchasing Act [30 ILCS 505/11.1] and the elective office held.

 

b)         An Application for WIC Vendor Authorization as a corporation shall include the following:

 

1)         identity and location of the corporation's principal place of business;

 

2)         identity and address of the corporation's registered agent;

 

3)         FEIN of the corporation;

 

4)         identification, address and date of birth of any individual with an ownership interest of 30% or more by the stockholders and such an ownership interest by these stockholders in any other entity applying for WIC Vendor Authorization or WIC Vendor;

 

5)         identification of the Business Entity, the Store Type, location of the proposed Vendor Site and an employee contact for WIC purposes;

 

6)         Certification of Incorporation from the state in which the Applicant is incorporated;

 

7)         identification, address and date of birth of each Corporate Officer;

 

8)         proof of identity for each Corporate Officer;

 

9)         proof of corporation's FEIN;

 

10)       proof of USDA Food Stamp Authorization, if applicable; and

 

11)       identification of any person holding elective office as specified in Section 672.210(a)(7) and Section 11.1 under the Illinois Purchasing Act [30 ILCS 505/11.1] and the elective office held.

 

c)         An Application for WIC Vendor Authorization as a partnership or limited partnership shall include the following:

 

1)         identity and address of each limited and general partner and the registered agent;

 

2)         ownership percentages of each limited and general partner;

 

3)         FEIN of of the partnership or limited partnership;

 

4)         identification of an ownership interest of 30% or more by the partners listed in subsection (c)(1) above and such an ownership interest by these partners in any other entity applying for WIC Vendor Authorization or WIC Vendor;

 

5)         identification of the Business Entity, the Store Type, location of the proposed Vendor Site and an employee contact for WIC purposes;

 

6)         proof of identity of each limited and general partner and date of birth;

 

7)         proof of the partnership or limited partnership FEIN;

 

8)         proof of USDA Food Stamp Authorization, if applicable;

 

9)         if a limited partnership, it must provide a Certificate of Existence issued by the Illinois Secretary of State; and

 

10)       identification of any person holding elective office as specified in Section 672.210(a)(7) and Section 11.1 under the Illinois Purchasing Act [30 ILCS 505/11.1] and the elective office held.

 

d)         An Application for WIC Vendor Authorization as a Limited Liability Company shall include the following:

 

1)         identity and address of the Limited Liability Company's principal place of business;

 

2)         identity and address of the Limited Liability Company's registered agent;

 

3)         FEIN of the Limited Liability Company;

 

4)         identification, address and date of birth of any individual with ownership interest of 30% or more by limited liability managers and such an ownership interest by these managers in any other entity applying for WIC Vendor Authorization or WIC Vendor;

 

5)         identification of the Business Entity, the Store Type, location of the proposed Vendor Site and an employee contact for WIC purposes;

 

6)         Proof of Organization (out of state Limited Liability Companies);

 

7)         proof of identity and date of birth for each limited liability manager;

 

8)         proof of the Limited Liability Company's FEIN;

 

9)         proof of USDA Food Stamp Authorization, if applicable; and

 

10)       identification of any person holding elective office as specified in Section 672.210(a)(7) and Section 11.1 under the Purchasing Act [30 ILCS 505/11.1] and the elective office held.

 

e)         Each owner, partner, limited partner, or shareholder of 5% or more of any stock shall also provide a statement concerning any conviction for a misdemeanor involving fraud, theft, or misuse of state or federal funds or any felony.

 

f)         Each Applicant or authorized representative shall attest to the accuracy of information provided in the Application.

 

g)         The Applicant shall have an obligation to notify the Department in writing, by Certified Mail, of material changes in information contained on the Application after Authorization and during the term of the WIC Vendor Authorization.

 

h)         Proof of FEIN shall include a copy of a notice of new employer identification number assigned or a copy of the Federal Tax Deposit Coupon.

 

i)          Proof of identity shall include a copy of the Applicant's driver's license or an identification card issued by the Illinois Secretary of State.

 

j)          If applicable, proof of USDA Food Stamp Authorization shall include a copy of the federal Food Stamp Program Authorization/Retailer Card.

 

k)         The Applicant shall provide documents which verify the date of purchase or acquisition of the Business Entity for which the Applicant is seeking WIC Vendor Authorization.

 

l)          Each Applicant shall attest to compliance with necessary local, municipal, or village licensing requirements at the proposed Vendor Site.

 

(Source:  Amended at 21 Ill. Reg. 3960, effective March 15, 1997)