Request to Increase Administrative Funds (RIAF)
Exhibit 2-C
PLEASE READ: This form is to be used by local WIC agencies to request an increase in authorized grant award to cover the costs of a non -recurring cost related to program
improvement or general infrastructure. If your agency is currently under spending the WIC grant, you might be able to proceed with the purchase you are considering without using
this form.
Name of LA:___________________________

Please discuss this request with your WIC consultant first.

Provide supporting documentation with the request.
Fiscal Year:____________________________

Send completed request and supporting documentation to your WIC Consultant.

Requests over $5000 must be submitted to USDA by MDH for approval. A letter of support from your Administrator is also required for this.

Approval may depend on availability of additional funds, appropriateness of the request and other factors.
Cost per item
Item(s) and quantity
(Include tax and delivery.
Rationale for purchasing items (how will this improve or enhance List labor and/or
WIC services in this local agency? What category does it fall under: training, installation on a separate
equipment, data systems, clinic environment/improvement, other?)
line)
Example: infant scale
We are creating a second lab space that requires its own scale. Will
help improve clinic flow and shorten time participants have to wait. $
What other
programs will
Percent of time share the cost
that item(s) will and by what
be used by WIC percent?
318.25
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Total Costs $
-
100 NA
List supporting documentation
with this request (quotes, bids,
estimates from vendors, tech specs,
letter of support from Administrator,
other documents)
tech specs, estimate from Scales
"R" Us dated 9/12/12
if greater than $5,000, the request must be sent to USDA for approval
Approvals:
Date
WIC Agency Administrator
Date
MDH Program/Nutrition Unit Supervisor
Date
MDH WIC Regional Consultant
Date
MDH Ops Unit Supervisor, if applicable
Date
MDH Fiscal Analyst
Date
MDH WIC Director
Forms can be submitted at any time, but must be submitted by September 15 for each fiscal year. If the request must go to USDA (over $5000) then the form must be submitted by
July 1 to ensure additional processing time. Agencies will receive a notification of approval/disapproval when processed and any approved requests will be included on the next
quarterly funding letter.
State Agency Comments:
2/2016