This government document is issued by Department of Health for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:-o2sxg2obgu&q=https://wic.health.pa.gov/pawic/documents/Outreach/English/WIC%2520Material%2520Order%2520Form.pdf&sa=U&ved=2ahUKEwjbtPPzs9D8AhUVolwKHUUuBnw4UBAWegQIBRAB&usg=AOvVaw0nHHCtbic9RFBpDND0-E1f