Fns-700

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TIP DATA ENTRY FORM

FORM APPROVED OMB NO 0584-0401

Add Vendor Information
Required entries are indicated by an asterisk (*)
Verify FNS Number
An FNS number may exist for this Vendor. To verify a number or determine if a number
exists, click Find FNS Number, which allows you to search for FNS stores, If you select
a store from the search results, the FNS-700 Form redisplays with the FNS Number
and the store location address copied to the appropriate fields. You can edit the data,
if needed.

*Vendor ID:

Enter a valid FNS Number below. To associate the FNS Number to the Vendor, click
Save. Leave blank, if there is no FNS Number.
FNS Number:
*Vendor Name:

New Vendor:

Street Number:

*Training:

$

Annual Redemptions:
Redemption Months:
Routine Monitoring Visits:

Street Name:
Additional Address
*City:

*State:

*Type of Vendor:

*Zip/Postal Code:

Zip + 4 Code:

Vendor Agreement:

Compliance Information
If you select On-Going for any investigation, enter data for either (1) Compliance Buys or (2) Inventory Audits.
If you select Completed for any Investigation, (1) indicate at least one indicator and (2) select a Reason for Sanction below.
Compliance Investigation:

*Risk Designation:

Investigations by Other Entity:

Date Referred to FSP:
If date is entered, Type of Sanction (below) must be set to Disqualified or CMP.
Month:

Number of Compliance Buys:

Day:

Year:

Number of Inventory Audits:

Indication Information
Redemption Indicators:
A - Extremely small amount of variation in food instrument prices - the individual food instrument prices do not vary
substantially
B - Large percent of food instruments redeemed at same price
C - Unusually high average food instrument prices - submitting extremely high average food instruments compared
with similar vendors
D- Redeemed prices are higher than their price list
Volume Indicators:
E - Large percent of high-priced food instruments
F - Volume of WIC business
G - Large increase of dollar volume of food instruments redeemed over time
H - Large percent of the area's total WIC redemptions
I - WIC sales are an unusually high percentage of vendor's total sales
J - High WIC to Food Stamp redemption ratio
K - WIC and Food Stamp sales are an unusually high percent of total sales
FORM FNS-700 (05-05) Previous Editions are Obsolete
Electronic Form Version Designed in Adobe 7.1 Version

SBU

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TIP DATA ENTRY FORM - Continued
Indication Information (continued)
Participant Indicators:
L - Participant/other complaints
M- Large number of participants redeeming food instruments outside of their health service area
N - Large number of participants redeeming food instruments who are considered to be at high health risk
O - Large number of food instruments with consecutive serial numbers
P - Large percentage of manually issued food instruments
Other Indicators:
Q - Excessive number of returned checks due to errors
R - Past history of violations and disqualifications
S - Associations with know violators
T - Multiple ownerships which include known violators
U - Short on authorized food items or no inventory
V - New vendor
Sanction Information
All Reason for Sanction choices require that a Type of Sanction be indicated below for all authorized vendors, except
for reasons that indicate "No Sanction".
Reason for Sanction:
Check all that apply. However, if you select No Sanction - Warning Letter or No Sanction, no other boxes can be checked.
T - Trafficking
A - Alcohol/Tobacco
I - Reimbursement in excess of documented inventory
O - Overcharging
R - Receiving/transacting or redeeming food instruments outside authorized channels
F - Charging for supplemental food not received
C - Providing credit or non-food items in exchange for Food instruments
U - Unauthorized food items in exchange for Food instruments
S - State agency sanction
FSP - Food Stamp Reciprocal Action
W - No Sanction - Warning Letter
N - No Sanction
Type of Sanction:
D - Disqualification (DQ)
C - Civil Money Penalties (CMP)
F - Fine
Administrative Review Information
Administrative Review:

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 information collection is 0584-0401. The time
required for completing this collection is estimated to range from 5 minutes to 434 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the
information collection.

FORM FNS-700 (05-05) Previous Editions are Obsolete

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