FNS-252 Food Stamp Application for Stores

Form FNS-252
US Department of Agriculture
Food and Nutrition Service

OMB No 0584-0008
Expiration Date XX/XX

FOOD STAMP APPLICATION FOR STORES
FNS Number

Authorization Initials

Date Authorized

/

FOR FIELD OFFICE USE ONLY

/

FNS Tracking Number
1 When did or when will the store open for business under your ownership (MM/DD/YYYY):

/

/

2 Store Name:

3 Chain Store Number (if applicable):

4 Store Location Address (do not enter PO Box here):
Street Number:
Street Name:

Additional Address (Bldg #, Unit #, Stall #, etc.):

City:

State:

Zip Code:

-

5 Store Mailing Address (Skip if your mailing address is the same as your store location. If you have a PO Box address, enter it in the street
name field):
Street Number:
Street Name:
Additional Address (Bldg #, Unit #, Suite #, etc.):
City:

State:

Zip Code:

6 Store Telephone Number:

(

)

If foreign address, add Country:

-

7 Alternate Telephone Number:

-

(

8 Do you want to receive official Food Stamp Program correspondence by email?
8a If yes, enter owner or store email address:

)

-

Yes

No

9 Is your business a delivery route, farmers' market or specialty food store that primarily sells one food type such as meat/poultry, seafood,
Yes

bread, or fruits/vegetables?
9a If Yes, check the one store type that best describes your store:
Meat/Poultry Market
Bakery
Seafood Market

No

Farmers' Market

Produce Market

Delivery Route

Privately Held Corporation

Sole Proprietorship

Limited Liability Company

Publicly Owned Corporation

Partnership

Nonprofit Cooperative

10 Type of Ownership (check only one box):
Government Owned

If privately held corporation or limited liability company, enter the name and address of your corporation as on record with the State.
If government owned, enter the name and address of the responsible government agency. If publicly owned corporation, enter the name and
address of the parent corporate office. All others skip to the next question.
11a Corporation Name:
11b Corporation Address:
Street Number:

Street Name:

Additional Address (Bldg #, Unit #, Suite #, etc.):

City:

State:

Zip Code:

11c If publicly owned or government owned, enter a contact person:
Contact Person Name:
Telephone Number:

(

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)

-

-

If foreign address, add Country:

Email Address:

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Enter the name and home address of all officers, owners, partners, and members. You must enter spousal information for each owner and
officer if your business is located in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI). If this is a public corporation or
government owned store, skip to question 13.
12a Print name as it appears on the social security card:
First Name:

Middle Name:

Street Number:

Last Name:

Street Name:

Additional Address (Unit #, Suite #, Apt #, etc.):

City:

State:

Zip Code:

If foreign address, add Country:

Social Security Number:

-

-

Date of Birth: (MM/DD/YYYY)

/

/

12b Print name as it appears on the social security card:
First Name:
Middle Name:
Street Number:

Business Title (i.e., owner, partner, spouse, etc.):

Last Name:

Street Name:

Additional Address (Unit #, Suite #, Apt #, etc.):

City:

State:

Zip Code:

If foreign address, add Country:

Social Security Number:

-

Date of Birth: (MM/DD/YYYY)

-

/

12c Print name as it appears on the social security card:
First Name:
Middle Name:
Street Number:

Last Name:

Street Name:

Additional Address (Unit #, Suite #, Apt #, etc.):

City:

State:

Social Security Number:

-

Business Title (i.e., owner, partner, spouse, etc.):

/

-

Date of Birth: (MM/DD/YYYY)

/

/

Zip Code:

-

If foreign address, add Country:

Business Title (i.e., owner, partner, spouse, etc.):

12d Print name as it appears on the social security card:
First Name:

Middle Name:

Street Number:

Last Name:

Street Name:

Additional Address (Unit #, Suite #, Apt #, etc.):

City:

State:

Social Security Number:

-

-

Date of Birth: (MM/DD/YYYY)

/

/

Zip Code:

-

If foreign address, add Country:

Business Title (i.e., owner, partner, spouse, etc.):

13

Has any officer, owner, partner, member, and/or manager ever had a license denied, withdrawn or suspended, or been fined for license
Yes
No
violations (i.e. Food Stamp, WIC, business, alcohol, tobacco, lottery, or health license)?
13a If yes, provide an explanation:

14

Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
14a If yes, provide an explanation:

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Yes

No

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15
16

Do you sell products wholesale to other businesses such as hospitals or restaurants?

Yes

No

15a If yes, does your retail food sales meet or exceed $250,000 and 50% of your total sales?

Yes

No

Does the sale of hot and/or cold freshly prepared foods that are ready-to-eat exceed 50% of your total sales?

Yes

No

Total Sales. Enter the total sales from all products you sell at this location. If your store has been open under your ownership for more than
one year, enter actual total sales from your most recent IRS tax return for this store (17a), or if your store has been open under your ownership
for less than one year, you must provide estimated sales (17b). You must complete either 17a or 17b.
17a Actual Sales: This store location had total sales of
17b Estimated Sales: I expect to gross
(check only one).

in tax year:

$

$

Day

in total sales per

Week

Month

Year

-

17c If you have an Employer Identification Number (EIN) enter it here:
18 Do you stock at least three different items in each of these food categories?
Bread/Grains

Yes

No

(Example: bread, cereal, pasta, rice, flour, etc.)

Dairy

Yes

No

(Example: milk, butter, cheese, yogurt, infant formula, etc.)

Fruits/Vegetables

Yes

No

(Example: corn, potatoes, green beans, apples, oranges, etc.)

Meat/Poultry/Fish

Yes

No

(Example: beef, chicken, pork, fish, etc.)

%

18a What percent of your total sales comes from these food categories?
18b Do you stock fresh, frozen or refrigerated foods in at least two of these categories?
19 Do you sell “other” foods, such as snack foods, soft drinks, or condiments?

Yes

No

Yes

No

%

19a If yes, what percent of your total sales comes from these items?
Yes

20 Do you sell non-food items or food that is hot at the time the customer pays for it?
20a If yes, check the items you carry:

tobacco products

alcohol

lottery

gasoline

hot food

other

No

%

20b If yes, what percent of your total sales comes from non-food and hot food items?

The sum of three percentage figures above must = 100 %
21 How many cash registers are at your store?
22 Is your store open year round?
Yes

22a If no, check which month(s) you are open:

No

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

23 Is this store open 7 days a week, 24 hours per day?

Yes

No

23a If no, indicate operating hours:
Opening Time

Select AM or PM

Closing Time

Select AM or PM

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

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PRIVACY ACT STATEMENT - Section 9 of the Food Stamp Act of 1977, 7 U.S.C. 2018, authorizes collection of the
information on this application.
•

Information is collected primarily for use by the Food and Nutrition Service in the administration of the Food Stamp Program;

•

Additional disclosure of this information may be made to other Food and Nutrition Service programs and to other Federal, State
or local agencies and investigative authorities when the Food Stamp Program becomes aware of a violation or possible violation
of the Food Stamp Act, as explained in the next section called "Use and Disclosure";

•

Section 278.1(b) of the Food Stamp Program regulations provides for the collection of the owners' Social Security Number (SSN),
Employee Identification Number (EIN) and tax information;

•

The use and disclosure of SSNs and EINs obtained by applicants is covered in the Social Security Act and the Internal Revenue
Code. In accordance with the Social Security Act and the Internal Revenue Code, applicant social security numbers and employer
identification numbers may be disclosed only to other Federal agencies authorized to have access to social security numbers and
employer identification numbers and maintain these numbers in their files, and only when the Secretary of Agriculture
determines that disclosure would assist in verifying and matching such information against information maintained by such
other agency [42 U.S.C. 405(c)(2)(C)(iii); 26 U.S.C. 6109(f)];

•

Furnishing the information on this form, including your SSN and EIN, is voluntary but failure to do so will result in denial of this
application;

•

The Food and Nutrition Service may provide you with an additional statement reflecting any additional uses of the information

furnished on this form.

USE AND DISCLOSURE - We may use the information you give us in the following ways;
•

We may disclose information to the Department of Justice (DOJ), a court or other tribunal, or another party before such tribunal
when the USDA is involved in a lawsuit or has an interest in litigation and it has been determined that the use of such information
is relevant and necessary and the disclosure is compatible with the purpose for which the information was collected;

•

In the event that the information in our system indicates a violation of the Food Stamp Act or any other Federal or State law
whether civil or criminal or regulatory in nature, we may disclose the information you give us to the appropriate agency, whether
Federal or State, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or
implementing the statute, or rule, regulation or order issued pursuant thereto;

•

We may use your information, including SSNs and EINs, to collect and report on delinquent debt and may disclose the information
to other Federal and State agencies, as well as private collection agencies, for purposes of claims collection actions including, but
not limited to, the Treasury Department for administrative or tax offset and referral to the Department of Justice for litigation.
(Note: SSNs and EINs will only be disclosed to Federal agencies authorized to possess such information);

•

We may disclose your information to other Federal and State agencies to verify the information, and to assist in the administration
and enforcement of the Food Stamp Act as well as other Federal and State laws. (Note: SSNs and EINs will only be disclosed to
Federal agencies authorized to possess such information);

•

We may disclose information to other Federal and State agencies to respond to specific requests from such Federal and State
agencies for the purpose of administering the Food Stamp Act as well as other Federal and State laws;

•

We may disclose information to other Federal and State agencies for the purpose of conducting computer matching programs;

•

We may disclose information to private entities having contractual agreements with us for designing, developing, and operating
our systems, and for verification and computer matching purposes;

•

We may disclose information to State agencies that administer the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC), authorized under section 17 of the Child Nutrition Act of 1966 for purposes of administering that Act and the
regulations issued under that Act;

•

We may disclose information to the public when a retailer has been disqualified or otherwise sanctioned for violations of the
Program after the time for administrative and judicial appeals has expired. This information is limited to the name and address of
the store, the owner(s) name(s) and information about the sanction itself. The purpose of such disclosure is to assist in the
administration and enforcement of the Food Stamp Act and Food Stamp Program regulations.

PENALTY WARNING STATEMENT - The Food and Nutrition Service can deny or withdraw your approval to accept food stamp
benefits if you provide false information or try to hide information we ask you to give us. In addition, if false information is provided
or information is hidden from the Food and Nutrition Service, the owners of the firm may be liable for a $10,000 fine or imprisoned for
as long as five years, or both (7 U.S.C. 2024(f) and 18 U.S.C. 1001).

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CERTIFICATION AND SIGNATURE - By signing below, you are confirming your understanding of and agreement with the following:
•

I am an owner of this firm;

•

I have provided truthful and complete information on this form and on any documents provided to the Food and Nutrition
Service;

•

If I provide false information, my application may be denied or withdrawn;

•

Any information I have provided or will provide may be verified and shared by the USDA with other agencies as described above;

•

By my signature below, I release my tax records to the Food and Nutrition Service;

•

I will receive Food Stamp Program training materials upon authorization. It is my responsibility to ensure that the training
materials are reviewed by all firm's owners and all employees (whether paid or unpaid, new, full-time or part-time); and that all
employees will follow Food Stamp Program regulations. If I do not receive these materials I must contact the Food and Nutrition
Service to request them;

•

I am aware that violations of program rules can result in administrative actions such as fines, sanctions, withdrawal or
disqualification from the Food Stamp Program; I am aware that violations of the Food Stamp Program rules can also result in
Federal, State and/or local criminal prosecution and sanctions;

•

I accept responsibility on behalf of the firm for violations of the Food Stamp Program regulations, including those committed by
any of the firm's employees, paid or unpaid, new, full-time or part-time. These include violations such as, but not limited to:
o
o
o
o

Trading cash for food stamp benefits (i.e. trafficking);
Accepting food stamp benefits as payment for ineligible items;
Accepting food stamp benefits as payment on credit accounts or loans;
Knowingly accepting food stamp benefits from people not authorized to use them;

•

Disqualification from the WIC Program may result in Food Stamp Program disqualification and a disqualification from
the Food Stamp Program may result in WIC Program disqualification;

•

In accordance with Federal law and U.S. Department of Agriculture policy, no customer may be discriminated against on the
grounds of race, color, national origin, sex, age, religion, political beliefs, or disability. Food stamp customers must be treated
in the same manner as non-food stamp customers;

•

Participation can be denied or withdrawn if my firm violates any laws or regulations issued by Federal, State or local agencies,
including civil rights laws and their implementing regulations;

•

I am responsible for reporting changes in the firm's ownership, address, type of business and operation to the Food and Nutrition
Service

Food Stamp Program authorization may not be transferred to new owners, partners, or corporations. An unauthorized individual or
firm accepting or redeeming food stamp benefits is subject to substantial fines and administrative sanctions.

I have read, understand and agree with the conditions of participation outlined in the Privacy Act, Use and Disclosure,
Penalty Warning and Certification Statements as provided above, and agree to comply with all statutory and regulatory
requirements associated with participation in the Food Stamp Program.

X

X
Signature

Print Name

Date Signed

Print Title

MAIL YOUR COMPLETED APPLICATION TO THE FOOD AND NUTRITION SERVICE ADDRESS FOR YOUR STATE
(SEE PAGE 1 OF INSTRUCTIONS).

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Instructions for Form FNS-252

United States Department of Agriculture

Food and Nutrition Service

Food Stamp Program Application for Stores
General Instructions

Use Form FNS-252, Food Stamp Program
Application for Stores to apply for authorization to
participate in the Food Stamp Program.

to the FNS Field Office address for your state. The
FNS Field Office address is listed on the cover letter
that was mailed to you with the application. You can
also find the FNS field office address for your state
at: http://www.fns.usda.gov/fsp.

These instructions should be used when submitting a
paper application by mail to USDA, Food and
Nutrition Service (FNS).

Authorization Processing Time

The information you provide on the application form
will be used by FNS to determine your store's
eligibility to accept and redeem Food Stamp Program
benefits. Your store may be visited as part of this
review. If approved, your store will be issued a Food
Stamp Program license.
You must train your employees on the Food Stamp
Program rules and regulations. Training materials
are available on our public web for your convenience
and included in your information packet if FNS
approves your application. You may also obtain
training information translated into other languages
from this site.

You must complete the application and submit all the
supporting documents before FNS processes your
application. An incomplete application or failure to
submit documentation will result in a delay. FNS
can take up to 45 days to process a completed
application

!
CAUTION

You cannot accept Food Stamp Program
benefits until you are authorized and
licensed by FNS.

Contact the FNS Field Office for your state to inquire
about the status of an application.

Specific Instructions

Print or type your answers so they are clear and
legible. Keep a copy of what you submit to FNS for
your records.

Reminders

You must answer all of the questions on the
application form, with the following exceptions:
TIP

If the store is owned by a sole
proprietorship, partnership or nonprofit
cooperative skip question 11.

Question 1 - Store Opening Date: Enter the
date that the store opened for business or will open
for business under your ownership. You can enter a
future opening date.

TIP

If the store is owned by a privately held
corporation or LLC skip question 11c.

Question 2 - Store Name: Enter the name

If the store is owned by a public corporation
or government agency skip question 12.

Question 3 - Chain Store Number: Enter

TIP

your store is doing business as.

How to Apply

You can apply online or submit a paper application
by mail. Use only one method.

Question 4 - Store Location Address:

Apply online: Go to the USDA, FNS website at:
http://www.fns.usda.gov/fsp and follow the
instructions to submit an online application.
Mail: Complete Form FNS-252, attach the required
documents, sign and date the application, and mail it

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the store number if the store is part of a chain of
stores and you refer to it by a number, i.e., “Fine
Foods #426”. Enter only the number in this field (do
not enter a pound sign).

Page 6

Enter the store location address. Do not enter a P.O.
Box number here. Use the Additional Address line
for the unit number, building number, stall number,
etc., for addresses with multiple stores at one
location.

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Question 5 - Store Mailing Address: If
your store has a mailing address that is different than
the location address, enter it here. If you have a P.O.
Box, enter it in the street name field.

Questions 6 - Store Telephone Number:
Enter the store's telephone number, including area
code.

Questions 7 - Alternate Telephone
Number: Enter an alternate telephone number,

including area code, such as a cellular number. We
may use the alternate telephone number to contact
you regarding your store during a disaster situation.

Question 8 - Official Correspondence:

Check the block to show if you would like to receive
official correspondence via email.
Question 8a: If yes, enter the email address where
you want to receive Food Stamp Program
information.

Question 9 - Special Store Type: Check this

box if your store is a farmers' market or delivery
route, or if you sell primarily just one type of food
(i.e., bread, meat, seafood, etc).
Question 9a: If yes, check the store type that applies.

For each Owner, Partner, Officer, Member,
Shareholder and Spouse: Enter the first name,
middle name, and last name of each person as it
appears on their social security card. Enter the home
address, social security number and date of birth for
each person.
If there are more than four primary owners make a
copy of page 2 and enter the additional person(s)
information. FNS does not collect information on
more than five primary owners.

Questions 13 and 14 - License
denials/violations, criminal convictions:

For each question, check only one box.
Question 13a and 14a: If you answer "Yes" to either
question 13 or 14 provide an explanation.

Question 15 - Wholesale Sales: Check the
box to show if this store sells products to other
businesses (i.e., sells to hospitals, restaurants, etc).
Question 15a: If yes, indicate if your retail food
sales meet or exceed $250,000 and 50% of the store's
total sales.
Question 16 - Hot and/or Cold Freshly
Prepared and Ready-to-Eat Foods: Check

Question 10 - Ownership Type: Select the
ownership type that best describes your business.

the box to show if the sale of hot and/or cold freshly
prepared ready-to-eat foods meet or exceed 50% of
your total sales.

Question 11 - Corporation or
Government Agency Information:

For privately held corporations and limited liability
companies, enter the name and address that is on
record with the State. For publicly owned
corporations, enter the parent corporation name and
address. For government owned stores, enter the
name and address of the responsible government
agency. For publicly owned corporations or
government owned stores enter the name, telephone
number and email address of the contact person or
the person responsible for the Food Stamp Program
license.

Question 17 - Total Sales: Enter the total sales
from everything you sell at this store location. If the
store has been in business for at least a year under
your ownership, provide the actual sales amount for
this store as reported to the Internal Revenue Service
in question 17a. If the store has been in business
under your ownership for less than a year, you may
enter estimated sales for an entire year in question
17b.
TIP

Question 12 - Owner, Officer, Member,
Shareholder Information: Do not complete

this question if you indicated the ownership type is
publicly owned corporation or government owned
store in question 10. For all other ownership types,
you must provide information for all primary owners,
partners, members and shareholders. Enter each
member's information if the store is owned by a nonprofit cooperative. In community property states
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(AZ, CA, ID, LA, NM, NV, TX, WA, and WI)
spousal information must be entered for each person
listed.

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You must complete either question 17a or
17b, but not both.

Question 17a - Actual Sales: Enter the actual total
sales amount as reported to the Internal Revenue
Service for this store and the tax year.
Question 17b - Estimated Sales: Enter an estimated
total sales amount as a daily, weekly, monthly, or
yearly figure, and check the method that you used
(daily/weekly/monthly/yearly).

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Question 17c - Federal Employer Identification
Number (EIN): An EIN is a nine digit number
assigned by the Internal Revenue Service to
businesses for tax filing and reporting purposes. If
you have an EIN number enter it exactly as assigned.

Question 18 - Food Inventory: For each of

the food categories listed check the block to show
whether or not your store stocks at least three
different types of food items in each category on a
daily basis. For example, cheese, milk, and yogurt
are different types of food; whole milk, skim milk,
and chocolate milk are not. Include fresh, frozen, and
canned foods when answering this question.
Question 18a - Sales Percent: Enter the percent of
your total sales that comes from the sale of these food
items.
Question 18b - Perishables: Check the box that
applies if you stock foods that are fresh, refrigerated
or frozen in at least two of the food categories listed
in question 18.

Question 19 - Other Foods: Check the box to
show if you sell other foods such as snack foods, soft
drinks and/or condiments.
Question 19a: If yes, enter the percent of your total
sales that come from the sale of these food items.
Question 20 - Non-Food/Hot Food: Check
the box to show if you sell any non-food items or
food that is hot when the customer pays for it.
Question 20a: If yes, check the boxes to show which
items you sell.
Question 20b: Enter the percent of your total sales
that comes from the sale of non-food items and hot
foods.
TIP

The sum of 18a, 19a and 20b must equal
100 percent.

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Question 21 - Number of Cash Registers:
Enter the number of cash registers at this store.

Question 22 - Store Open Year Round:

Check the box to indicate if your store is open yearround.
Question 22a: If no, check the boxes next to the
months your store is open for business.

Question 23 - Open 24/7: Check the box to

indicate if your store is open 24 hours a day, 7 days a
week.
Question 23a: If no, enter the opening and closing
time for each day your store is open for business and
indicate AM or PM.

Privacy Act and Paperwork Reduction
Notice.
Public reporting burden for this collection of information is
estimated to average 11 minutes 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. An agency may not
conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden
estimate (0584-0008) or any other aspect of this collection of
information, including suggestions for reducing this burden, to:
U.S. Department of Agriculture, Food and Nutrition Service,
Office of Research, Nutrition and Analysis, 3101 Park Center Dr.,
Alexandria, VA 22302. Do not return the completed form to this
address. Instead, see How to Apply section.
To file a complaint of Discrimination, write to the USDA,
Director, Office of Civil Rights, Room 326W Whitten
Building, 1400 Independence Ave, SW, Washington, D.C.
20250-9410. Do not send the completed application form to
this address.

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