4 - Attach 4_Sample Checks 110317~2.pdf

New jersey ) NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN CITIZENS ALLIANCE BANK,i MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. HOWARD LAKE BRANCH

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.gov/olg/hotlIne.htm. 75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE II AMOL INT AITERED 10981295

Account 806805

WIC I.D. NO.

13921188

NAME OF PARTICIPANT

JERSEY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 121 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED

005 Enfamil AR 12.9 oz Powder

XXX END OF ORDER XXXX

Pay to the order of: Corrected $ Amount:

VENDOR: FILL IN

DOLLAR AMOUNT BELOW

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CITIZENS ALLIANCE BANK

HOWARD LAKE BRANCH1C

MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLAFtA CITY, MN 56222

TO REPORT SUSPECTED ABUSE, (AU. 800-424-9121 OR VISIT www.usda.gov/oIg/hotlIne.htm. 75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE A AMOUNT ALTERED 10981296

Account 806805

WIC I.D. NO. NAME OF PARTICIPANT Fl TYPE PROG/SITE FIRST DAY TO USE LAST DAY TO USE

13921188 JERSEY ROCKER WIC 03/01/01 OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY SEE LIST. NO SUBSTITUTIONS ALLOWED.

004 Enfamil AR 12.9 oz Powder

XXX END OF ORDER XXXX

Pay to the order of:

11.

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VENDOR: FILL IN

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Attachment #4 – Sample NJ WIC Checks

New Jerseg .1 NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

CITIZENS ALLIANCE BANK

HOWARD LAKE BRANCH

1 c MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.

BUYING, SELLING OR OTHERVVISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222

TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.goviolg/hotlIne.htm. 75-1248/919

AUTHORIZED REPRESENTAT.VE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981349

Account 806805

WIC I.D. NO.

13921197

NAME OF PARTICIPANT

ZELDA ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY SEE LIST. NO SUBSTITUTIONS ALLOWED

016 Enfamil Infant 13 oz Concentrate

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

VENDOR: FILL IN

DOLLAR AMOUNT BELOW

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000 L098 L 3 1,90 1:09L 21: 806805116

..) NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

CITIZENS ALLIANCE BANKMISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. HOWARD LAKE BRANCHlc BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222

TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.goviolg/hotlIne.htm. 75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981350

Account 806805

WIC I.D. NO.

13921197

NAME OF PARTICIPANT -

ZELDA ROCKER

Fl TYPE

WIC

PROGISITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

;OR PURCHASE OF APPROVED ITEN S ONLY SEE LIST. NO SUBSTITUTIONS ALLOWED.

015 Enfamil Infant 13 oz Concentrate

XXX END OF ORDER XXXX

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Corrected S Amount:

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111,00 L098 L 3 SOP 1:09 L9 L 21,8 21: 8068050

) NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

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TO REPORT SBUUSYPINECTIG.

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HOWARD LAKE BRANCH

CLARA CITY MN 56222

75-1248/919

AUTHORIZED REPRESENTATNE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981307

Account 806805

WIC I.D. NO.

13921190

NAME OF PARTICIPANT

BUZZY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

009 8oz (6 packs) Enfamil AR Ready to Use

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

VENDOR: FILL IN

DOLLAR AMOUNT BELOW

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Sc, POO L098130 vP 409 L9 L 24E124 8068050

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MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. HOWARD LAKE BRANCH

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME.

CITIZENS ALLIANCE BANK1 c

CLARA CITY, MN 56222

TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.gov/olg/hotline.htm. 75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981308

Account 806805

WIC I D NO.

13921190

NAME OF PARTICIPANT

BUZZY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13 , 2017674 NOV 12, 2017

FOR ' ,CHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED

008 8oz (6 packs) Enfamil AR Ready to Use

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

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VENDOR: FILL IN

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PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

Sc, POO L0913 L3080 1:09 L9 L24821: E1068050

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) NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

CITIZENS ALLIANCE BANKMISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME.

TO REPORT

HOWARD LAKE BRANCH

CLARA CITY MN 56222

SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.goviolg/hotlIne.htm. 75-1248/919

AUTHORIZED REPRESENTAT VE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981313

Account 806805

WIC I.D. NO.

13921191

NAME OF PARTICIPANT

MUGSY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED

005 Enfamil Gentlease 12.4 oz Powder

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

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VENDOR: FILL IN

DOLLAR AMOUNT BELOW

Must Deposit By: DEC 12, 2017

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

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POO LO9a L31.30 1:09 L9 L2Iii321.1 806e3D5P

NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

CITIZENS ALLIANCE BANKMISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. HOWARD LAKE BRANCH i C BUYING, SELLING OR OTHERVVISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT ww.v.usda.goviolg/hotline.htm. 75-1248/919

PROXY.

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Account 806805

WIC I.D. NO.

13921191

NAME OF PARTICIPANT

MUGSY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED

004 Enfamil Gentlease 12.4 oz Powder

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

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VENDOR: FILL IN

L.tct AMOUNT BELOW

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PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

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CITIZENS ALLIANCE BANK

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MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.goviolg/hotlIne.htm.

HOWARD LAKE BRANCH

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981319

Account 806805

WIC I.D. NO.

13921192

NAME OF PARTICIPANT

LIBBY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

005 Enfamil Infant 12.5 oz Powder

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

VENDOR: FILL IN

DOLLAR AMOUNT BELOW

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ph, 000 LO9a L 3 L9101 C:09 L9 L 248 21:

.1 NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

CITIZENS ALLIANCE BANK

1C

MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.goviolg/hotlIne.htm.

HOWARD LAKE BRANCH

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981320

Account 806805

WIC I.D. NO.

13921192

NAME OF PARTICIPANT

LIBBY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

004 Enfamil Infant 12.5 oz Powder

XXX END OF ORDER XXXX

Pay to the order of:

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Payment denied without stamp

Corrected S Amount:

VENDOR: FILL IN

,-_'. AR AMOUNT BELOWCv vr,,v .v.

Must Deposit By: DEC 12 2017

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

0, 000 LO9a L 3 200 1:09 L9 L 2 11a 21: 80E430 50

Lc:: jersey NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. CITIZENS ALLIANCE BANK

HOWARD LAKE BRANCHBUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.goviolg/hotlIne.htm. 75-1248/919

WIC 1.D. NO.

AUTHORIZED REPRESENTAT VE OR

PROXY SIGN HERE IF AMOUNT ALTERED

NAME OF PARTICIPANT Fl TYPE PROG/SITE

13921193 PUNKY ROCKER WIC 03/01/01

FIRST DAY TO USE

10981325 Account 806805

LAST DAY TO USE

NOV 12, 2017

FOR PURCHASE OF APPROVED ITEN S ONLY SEE LIST. NO SUBSTITUTIONS ALLOWED.

009 8oz (6 packs) Enfamil Infant Ready to Use

XXX END OF ORDER XXXX

Pay to the order of: Corrected $ Amount:

1 ,4414k Must Deposit By: DEC 12, 2017

AA:

Payment denied without stamp

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PIURCII

"6 00 L098 L3 25P 1:09 L9 L 24E1 21: 80680 so

N..“7,21.9 .1 NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

i c MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. CITIZENS ALLIANCE BANK

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA or( MN 56222TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT www.usda.gov/olg/hotlIne.htm.

HOWARD LAKE BRANCH

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981326

Account 806805

WIC I.D. NO.

13921193

NAME OF PARTICIPANT

PUNKY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

008 8oz (6 packs) Enfamil Infant Ready to Use

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

0.••....$0+

Payment denied without stamp

VENDOR: FILL INDOLLAR AMOUNT BELOW

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Must Deposit By: DEC 12 2017

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

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000 /098 L3 260 409 /9L 2413 21:

Jemy ) NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. CITIZENS ALLIANCE BANK

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800.424-9121 OR VISIT www.usda.gov/olg/hotlIne.htm.

HOWARD LAKE BRANCH

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981343

Account 806805

WIC I.D. NO.

13921196

NAME OF PARTICIPANT

ZIGGY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY SEE LIST. NO SUBSTITUTIONS ALLOWED.

009 8oz (6 packs) Prosobee Ready to Use XXX END OF ORDER XXXXt,..

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000 L09E1 L 31 30 1:09 L9 L 2 1.18 21: 130680

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IT www.usda.govioig/hotlIne.htm.

CHOZIRSDA:AIKE REA IBVACNHK

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222

TO REPORT SUSPECTED ABUSE, CALL 800-424-9121 OR VISIT 75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981344

Account 806805

WIC ID.NO.

13921196

NAME OF PARTICIPANT

ZIGGY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

008 8oz (6 packs) Prosobee Ready to Use

XXX END OF ORDER XXXX

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000 L0913 L 341.10 1:09 L9 248 21: 8068050

N. Jersey .3 NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN CITIZENS ALLIANCE BANKMISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.i

LLI BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CIARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800.424-9121 OR VISIT www.usda.goviolg/hotline.htm.

HOWARD LAKE BRANCH

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981337

Account 806805

WIC I.D. NO.

13921195

NAME OF PARTICIPANT

NELLIE ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

005 Enfamil Prosobee 12.9 oz Powder

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

VENDOR: FILL IN

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NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED. CITIZENS ALLIANCE

BANK10981338

ESDELALBINUGSE0R OTHERVIS2E4.M9I1S2U1SOIHRGVW1IsaC BENEFITS aIS.gA.C/1101,9M/Eh. otline.htm.

HOWARD LAKE BRANCH

l TO R RT

BUYING, CLARA CITY MN 56222

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN FIERE IF AMOUNT ALTERED

Account 806805

WIC ID.NO.

13921195

NAME OF PARTICIPANT

NELLIE ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY SEE LIST. NO SUBSTITUTIONS ALLOWED.

004 Enfamil Prosobee 12.9 oz Powder

XXX END OF ORDER XXXX

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VENDOR: FILL IN

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Must Deposit By: DEC 12 2017

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

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POO LO9a L338118 1:09 L9 L2141324 806805111 t... Jersey j NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN CITIZENS ALLIANCE BANK1 c MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED, HOWARD LAKE BRANCH

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLAFtA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800424-9121 OR VISIT www.usda.goviolg/hotlIne.htm. 75-1248/919

AUTHORIZED REPRESENTAT NE OR

PROXY SIGN HERE IF AMOUNT ALTFRID 10981331

Account 806805

WIC I.D. NO.

13921194

NAME OF PARTICIPANT

JOEY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED ITEMS ONLY. SEE LIST. NO SUBSTITUTIONS ALLOWED.

016 Enfamil Prosobee 13 oz Concentrate

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

O.

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Payment denied without stamp

VENDOR: FILL IN

DOLLAR AMOUNT BELOW

• • #1 , Must Deposit By: DEC 12, 2017

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

mp

000 LOSE L 33 LH° 1:09 LciL 21,a 21:

NEW JERSEY WIC SERVICES PAYABLE THROUGH SOLUTRAN

CITIZENS ALLIANCE BANK

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MISUSE OF DRAFTS SUBJECT TO STATE OR FEDERAL PROSECUTION. VOID IF ALTERED.

BUYING, SELLING OR OTHERWISE MISUSING WIC BENEFITS IS A CRIME. CLARA CITY MN 56222 TO REPORT SUSPECTED ABUSE, CALL 800424-9121 OR VISIT www.usda.gov/olg/hotIlne.htm.

HOWARD LAKE BRANCH

75-1248/919

AUTHORIZED REPRESENTATIVE OR

PROXY SIGN HERE IF AMOUNT ALTERED 10981332

Account 806805

WIC I.D. NO.

13921194

NAME OF PARTICIPANT

JOEY ROCKER

Fl TYPE

WIC

PROG/SITE

03/01/01

FIRST DAY TO USE LAST DAY TO USE

OCT 13, 2017 NOV 12, 2017

FOR PURCHASE OF APPROVED !TEN S ONLY. SEE LIST, NO SUBSTITUTIONS ALLOWED.

015 Enfamil Prosobee 13 oz Concentrate

XXX END OF ORDER XXXX

Pay to the order of: Corrected S Amount:

04 t- ‘- VENDOR: FILL INDOLLAR AMOUNT BELOW00. v.).".,a• r r • • , 47

Payment denied without stamp

''ster fk‘

Must Deposit By: DEC 12, 2017

PARTICIPANT: DO NOT SIGN UNTIL TIME OF PURCHASE

mp

000 LO 9a L3320 1:09 L9 21-,a 21: 806805o