Form FNS-278B Food Stamp Redemption Certificate

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The documents in this booklet are
NONTRANSFERABLE

U.S. DEPARTMENT
OF AGRICULTURE
Food and
Nutrition Service

FOOD STAMP REDEMPTION CERTIFICATE

Instructions to the Retailer
(Refer to the sample document on the inside back cover.)

1. Enter the value of the food coupon deposit by denomination (i.e., $1, $5, and $10).
2. Enter the total value of the deposit in "Firm's Total".
3. Read the certification statement.
4. The firm's authorized representative must print their name and date. In the space
marked "Signature of Firm's Representative" sign and indicate title.
WARNING: By signing this form you are certifying that the owner and business location
is currently authorized to accept and redeem food stamp benefits. To prevent illegal use,
do not use this form if there has been a change of ownership, name of business, and/or
operation of the firm. Use of this certificate by any individual or firm which is not
currently authorized by FNS may result in substantial fines and administrative sanctions.

IMPORTANT NOTICE
YOU MUST REPORT ANY CHANGES IN OWNERSHIP OR LOCATION OF THIS FIRM
TO FNS. IF YOU DO NOT, YOU MAY BE SUBJECT TO A MONETARY PENALTY
OR REMOVED FROM THE FOOD STAMP PROGRAM.
PLEASE REPORT ANY CHANGES IN OWNERSHIP OR LOCATION TO THE FNS FIELD
OFFICE AT AREA CODE (xxx) xxx-xxxx UNLESS YOU ARE A CHAIN STORE AND
YOUR STORES ARE MANAGED THROUGH ONE FNS POINT OF CONTACT, THEN
CHANGES IN OWNERSHIP OR LOCATION MUST BE REPORTED TO THE MANAGING
FNS FIELD OFFICE.
THE DOCUMENTS IN THIS BOOKLET ARE NONTRANSFERABLE. IF THE FIRM IS
SOLD, THESE REDEMPTION CERTIFICATES MAY NOT BE USED BY A NEW OWNER.

SBU

Electronic Form Version Designed in Adobe 7.1 Version

FORM APPROVED OMB NO. 0584-0085
FORM FNS-278B (11-01) USDA-FNS

DO NOT BORROW, LEND OR MAKE
DUPLICATES OF REDEMPTION CERTIFICATES

FOOD STAMP REDEMPTION CERTIFICATE
NON-TRANSFERABLE

$ 1.00

$

$ 5.00

$

$ 10.00

$

Date

FIRM'S TOTAL $

Signature of Firm's Representative

Title

BANK'S
VERIFIED TOTAL $
BANK MUST CERTIFY ON REVERSE

I certify that the firm's total is accurate, and the accompanying food coupons were accepted, and are being redeemed
in accordance with Food Stamp Program regulations. I further certify that the firm's owner (or a representative), is
CURRENTLY APPROVED by FNS to accept and redeem food coupons.

COUPONS

BANK CERTIFICATION

I certify that the amount shown in the
bank's verified total is accurate and
that coupons were accepted in accordance with the Food Stamp Program
regulations.

DATE

FOOD STAMP REDEMPTION CERTIFICATE
NON-TRANSFERABLE

TELLER'S SIGNATURE

Redemption Certificates must accompany food
coupons for reconciliation by the Federal Reserve
Bank.

Place Bank or Teller
Stamp Here

BANK NAME AND ADDRESS

1. Ensure that retailer completes all information.
2. Verify value of this food coupon deposit and enter
in "Bank's Verified Total" block. If differs from
firm's total, do not correct firm's total block.
3. Certify the food coupon deposit at right.
4. Per FRB, MICR encode correct amount on MICR line.
5. Write name and address of bank accepting this
deposit in space at right.

FORM APPROVED OMB NO. 0584-0085
FORM FNS-278B (11-01) USDA-FNS

VALUE

Print Name of Firm's Representative

Instructions to the Bank

DO NOT BORROW, LEND OR MAKE
DUPLICATES OF REDEMPTION CERTIFICATES

COUPONS

VALUE

$ 1.00

$

$ 5.00

$

$ 10.00

$

Print Name of Firm's Representative

Date

FIRM'S TOTAL $

Signature of Firm's Representative

Title

BANK'S
VERIFIED TOTAL $
BANK MUST CERTIFY ON REVERSE

I certify that the firm's total is accurate, and the accompanying food coupons were accepted, and are being redeemed
in accordance with Food Stamp Program regulations. I further certify that the firm's owner (or a representative), is
CURRENTLY APPROVED by FNS to accept and redeem food coupons.

NOTE:
For information or ADDITIONAL SUPPLIES OF THE REDEMPTION
CERTIFICATE, contact your FNS Field Office at the PHONE NUMBER
included on the insert in front of this booklet.
ESTIMATE OF BURDEN HOURS
FOOD STAMP REDEMPTION CERTIFICATE
According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this formation collection is 0584-0085. The time required to
complete this information collection is estimated to average .020 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information.

Return Service Requested

OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE, $300

U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE
PO BOX 135
MINNEAPOLIS, MINNESOTA 55440
FIRST-CLASS MAIL
POSTAGE & FEES PAID
FOOD & NUTRITION
SERVICE
Permit No. G-39