Customer Incident Report (for stores to complete)

Please complete this report with as much information as possible to report an incident of rude or otherwise inappropriate behavior by a WIC participant. This form is not meant to be used to report issues with your POS system.

Contact Information

Name (First & Last)

Title

Email Address

Phone

Store Name (Chain stores, please include store number)

Store Address

Store County

Name and title of store staff person(s) involved in this incident:

Date of Incident

Format: mm/dd/yyyy

Approximate time of Incident

Transaction Amount

Did the customer leave the store with foods for which their card was not charged?

Is it possible that the customer's card was charged for foods they did not receive?

Name of Cardholder (if known)

Card Number (if known)

What happened? Please check applicable box(es), and then give details below.

Customer did not treat cashier courteously.
Customer did not follow correct WIC benefit redemption procedures.
Customer tried to buy foods that weren't in their balance and/or WIC allowed.
Other

Please describe, in as much detail as possible, what the customer did or said and what happened.

Is security footage of the incident available?

Upload images of receipt #1 (if available).

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Image:

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Upload images of receipt #2 (if available).

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Image:

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Upload images of receipt #3 (if available).

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Image:

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