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 (RD), Lactation Services, Improving Client Experience (ICE), Innovation, Dietetic Internship, etc.) Attached are more detailed explanations of cost categories.
General Administration: Expenditures generally considered being overhead or management costs. Can also include RD administrative expense.
Client Services: Expenditures for certification, food delivery and other client services and benefits. Can also include RD, ICE, and extra administration expense.
Nutrition Education: Expenditures for general nutrition education (NE). Include RD and ICE NE expense, Dietetic Intern, and Innovation expense.
Breastfeeding: Expenditures for breastfeeding promotion and support. Includes PC, Peer Dad, lactation services, and BF portion of RD expenses.
Total: Add blocks 5-8.*
Block 10: Signature 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.
*If using the March billing amount, the total should equal all vouchers submitted.