FNS 252-2 USDA Supplemental Nutrition Assistance Program - Applica

OMB No. 0584-0008
Expiration Date 07/11

USDA Supplemental Nutrition Assistance Program
Application for Meal Services

FOR USDA USE ONLY
FNS Number:
Date Authorized:
Authorization Initials:
Sponsor Type:
County Code:

Part 1 - Meal Service Types
Directions: Review the descriptions below and check the meal service type that describes the meal service.
You may only check one box (one meal service type) per application.
Private For-Profit Restaurant or Private For-Profit Meal Delivery Service
means private for-profit establishments that contract with an appropriate
State or local agency to offer meals at concessional prices to homeless
individuals, elderly persons and their spouses or supplemental security
income (SSI) recipients and their spouses.

Private For-Profit Restaurant

Drug and/or Alcohol Treatment Program means any drug addiction or
alcoholic treatment and rehabilitation program conducted by a private
nonprofit organization or institution, or a publicly operated community
mental health center, that is operating under part B of Title XIX of the
Public Health Service Act (42 U.S.C. 300x et. seq.).

Private Nonprofit
Organization/Institution

Private For-Profit Meal Delivery
Franchise

yes

no

Publicly Operated
Organization/Institution

Meal Delivery Service means a public or a private nonprofit organization
that prepares and delivers meals to elderly persons and their spouses and/
or to the physically or mentally handicapped and persons otherwise
disabled, and their spouses if they are unable to adequately prepare all of
their meals.

Public Meal Delivery
Private Nonprofit Meal Delivery

Communal Dining Facility means a public or private nonprofit
establishment that prepares and serves meals for elderly persons and
their spouses or for SSI recipients and their spouses.

Public Communal Facility
Private Nonprofit Communal
Facility

Homeless Meal Provider means a public or private nonprofit establishment
(e.g., soup kitchen, temporary shelter), approved by an appropriate State or
local agency, that feeds homeless persons. If the site receives donated
food items from USDA, the site must also purchase and serve other food.

Public Establishment
Private Nonprofit Establishment

Shelter for Battered Women and Children means a public or private
nonprofit residential facility that serves meals or provides food to battered
women and children. If such a facility serves other individuals, part of the
facility must be set aside on a long-term basis to serve battered women
and children.

Public Facility
Private Nonprofit Facility

Group Living Arrangement means a public or private nonprofit residential
setting that serves no more than 16 residents and that is certified by the
appropriate State agency(ies) in accordance with 1616(e) of the Social
Security Act or standards determined by USDA to be comparable.

Public Facility
Private Nonprofit Facility

Private For-Profit Senior Citizens' Center or Residential Building means a
facility that prepares and serves meals to elderly or SSI recipients.
Participating residential buildings must be occupied primarily by elderly or SSI
recipients.

Senior Citizens Center
Residential Building

You need to complete a separate FNS-252-2 application for each type of meal service you operate.

SBU

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Electronic Form Version Designed in Adobe 8.1 Version

OMB No. 0584-0008
*Part 2 - Sponsoring Organization or Business
Directions: All applicants must complete this section.
Name:
Doing Business As (if applicable):
Mailing Address:
City:

State:

Zip:

Federal Employer Identification Number (EIN), if applicable:
Name of Person Responsible for Operation of Meal Service:
Title:
Telephone: (
)
Fax, optional:
E-mail, optional:
If this is a private for-profit restaurant, private for-profit meal delivery service, or private for-profit senior citizens
center or residential building, you must also complete Part 4.
Part 3 - Site Specific Information - Site Where Meals Are Served
Directions: All applicants must complete this section. You must provide information on all meal sites under the
meal service's sponsorship.
Number of sites to accept Supplemental Nutrition Assistance Program benefits:
Site Name #1
Location Address:
City:
Check days of operation:
Meals served:

State:
M

T

W

Breakfast

TH

F

SA

Lunch

Zip:
SU
Dinner

Person Responsible for On-Site Operation, if different from Part 2:
Title:
Telephone:
If a Group Living Arrangement, number of residents served:
Site Name #2
Location Address:
City:
State:
Check days of operation:
Meals served:

M

T

W

Breakfast

TH

F

SA

Lunch

Zip:
SU
Dinner

Person Responsible for On-Site Operation, if different from Part 2:
Title:
Telephone:
If a Group Living Arrangement, number of residents served:
Site Name #3
Location Address:
State:
City:
Check days of operation:
Meals served:

M
Breakfast

T

W

TH

F

Lunch

SA

Zip:
SU
Dinner

Person Responsible for On-Site Operation, if different from Part 2:
Title:
Telephone:
If a Group Living Arrangement, number of residents served:
List additional sites on a separate sheet of paper and attach, using the same format above.
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OMB No. 0584-0008
Part 4 - Ownership Information

NA

Directions: Complete this section only if you are a private for-profit restaurant, private for-profit meal delivery
service, or private for-profit senior citizens center or residential building.
Form of Ownership:
Sole Proprietorship
Partnership
Privately-held corporation
Limited Liability Company
Publicly-owned Corporation (if you check this, skip to Part 5)
Enter primary owner(s) or corporate officer(s) if one or if more people or a private for-profit corporation owns the
meal service. In community property states, the spouse's information must also be entered. Community
property states are: Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, the state of Washington,
and Wisconsin. Print names as they appear on the social security card.
Name (First, Middle, Last):
Title:

Social Security Number:

Date of Birth:
Home Address:
City:

State:

Zip:

Enter other owner's or officers; information below, if applicable.
Name (First, Middle, Last):
Title:

Social Security Number:

Date of Birth:
Home Address:
City:

State:

Zip:

Name (First, Middle, Last):
Title:

Social Security Number:

Date of Birth:
Home Address:
City:

State:

Zip:

FOR FNS USE ONLY

SUBMIT APPLICATION TO YOUR LOCAL
FNS FIELD OFFICE.

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OMB No. 0584-0008
Part 5 - Agreement and Signature Block
I understand and agree:
I have the authority to contract for the meal service.
I have provided truthful and complete information on this form.
I hereby agree to release to the Department of Agriculture (USDA), by my signature below my tax
records and also to allow USDA to verify the accuracy of information submitted with this application.
Any information I provide may be verified and shared by/with other agencies as
described in attachment B.
If I provide false information, my application may be denied or withdrawn.
I accept responsibility to report changes in the meal service's ownership, address, type of business, and
operation to the FNS field office.
I will follow, and ensure representatives will follow, the Supplemental Nutrition Assistance Program regulations.
I am aware that violations of program rules can result in fines, legal sanctions, withdrawal, or disqualification from
the Supplemental Nutrition Assistance Program.
I accept responsibility on behalf of the meal service for violations of the Supplemental Nutrition Assistance Program
regulations, including those committed by any of the meal service's representatives, both paid or unpaid, new,
full-time or part-time. These include violations, such as but not limited to:
Trading cash for Supplemental Nutrition Assistance Program benefits
Knowingly accepting Supplemental Nutrition Assistance Program benefits from people not authorized to
use them
Accepting Supplemental Nutrition Assistance Program benefits as payments on credit accounts or loans
Using Supplemental Nutrition Assistance Program benefits to cover the cost of room and board or treating
Supplemental Nutrition Assistance Program customers differently than other customers
Accepting Supplemental Nutrition Assistance Program benefits as payments for ineligible items
Participation can be denied or withdrawn if the meal service violates any laws or regulations issued by
Federal, State or local agencies, including civil rights laws and their implementing regulations.
Participation in the Supplemental Nutrition Assistance Program requires that I will not discriminate against any
customer on the grounds of race, color, national origin, age, sex, handicap (disability), political belief or
religion; and that I will immediately take any measures necessary to make sure that my customers
are not discriminated against.
Any individual or meal service accepting or redeeming Supplemental Nutrition Assistance Program benefits, if not
authorized to do so, is subject to substantial fines and administrative sanctions.
Approval to participate will be automatically withdrawn and the meal service will no longer be able to
accept Supplemental Nutrition Assistance Program benefits upon loss of Federal tax-exempt status, cancellation or
expiration of its contract with the State or local agency, or loss of its State certification, if required as a condition of
eligibility.
I have read and understand the Privacy Act Statement, Warnings, and Certification as provided in
attachment B.
Has the owner(s), manager(s), and/or officer(s) ever had a license denied, withdrawn, or suspended, or been
fined for license violations (such as the Supplemental Nutrition Assistance Program, business, alcohol, tobacco, lottery,
or health licenses)? If yes, provide an explanation on a separate sheet of paper.
Yes
No
Has any individual involved in the ownership or management of the meal service ever been convicted of any
crime? If yes, provide an explanation on a separate sheet of paper.
Yes
No
Print Name:

Print Title:

Signature:

Date Signed:

Submit the supporting documentation as requested in Attachment A. If you have any questions, contact your
local field office.
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ATTACHMENT A - MEAL SERVICE APPLICATION REQUIRED DOCUMENTATION LIST
Directions: Provide all of the required documentation for the meal service type for which you are applying,
along with the completed application form. Please keep attachments A and B for your records.
SECTION A: Private For-Profit Restaurant or For-Profit Meal Delivery Service
Required Documentation: (Provide all of the following)
Copy of a government issued photo identification card and a copy of a Social Security card, or other
verification of Social Security Number, for:
all owners/partners
all officer(s) of private corporations
also provide for spouses of owners/officers if store is located in a community property State
(see Part 4 of the application)
NOTE: Above documentation is not required for publicly-owned corporations
Copy of the contract with the State agency
Copy of a valid business license
SECTION B: Alcohol and / or Drug Treatment Program
Required Documentation:
Proof of tax-exempt status as recognized by the Internal Revenue Service
Certified by the State agency responsible for the rehabilitation of drug addicts or alcoholics (the State Title
XIX agency) as:
i. Receiving part B Title XIX funding; or
ii. Operating under part B Title XIX even if no funds are being received; or
iii. Operating to further the purposes of part B of Title XIX, to provide treatment and rehabilitation
of drug addicts and/or alcoholics.
SECTION C: Public or Private NonProfit Meal Delivery Service; Public or Private NonProfit Communal Dining
Facility; Public or Private NonProfit Homeless Meal Provider; Shelter for Battered Women and Children
Required Documentation: For the four meal service types listed above, provide proof of the meal service's
tax-exempt status as recognized by the Internal Revenue Service.
SECTION D: Group Living Arrangement
Required Documentation:
Proof of tax-exempt status as recognized by the Internal Revenue Service.
Certification by the appropriate State agency in accordance with regulations issued under 1616(e)
of the Social Security Act or under comparable standards, as determined by the U.S. Department
of Agriculture.
SECTION E: Private For-Profit Senior Citizens' Center or Residential Building
Required Documentation:
If applying as a Residential Building, a signed statement from the owner(s) certifying: (1) that the
building is occupied primarily by elderly persons (60 years of age or older) and SSI recipients and
that it prepares and serves meals to such persons, and (2) that it does not provide a majority of
the residents' meals (over 50 percent of three meals daily) as part of the institution's normal services.

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OMB No. 0584-0008

ATTACHMENT B
Privacy Act Statement - Section 9 of the Food and Nutrition Act of 2008, as amended, (Title 7 U.S.C. 2011 et seq.)
authorizes collection of this information. The primary use of this information is for the Supplemental Nutrition Assistance
Program. Additional disclosures of the information may be to other FNS programs within Federal, State or local offices
and investigative authorities, including local law enforcement agencies, when the Supplemental Nutrition Assistance Program
becomes aware of a violation or possible violation of the Food and Nutrition Act, as explained in the next section of this document
called "Use and Disclosure" [Title 7 U.S.C. 2018(c), Title 26 U.S.C. 6109(f), Title 42 U.S.C. 405(c) and Title
U.S.C. 770119].
Where the owners' identification number is your Social Security Number (SSN), collection of this information is
authorized by Section 271.1(b) of program regulations. Under this Section, we are also allowed to collect your
Employee Identification Number (EIN) and tax information. We can only share SSNs and EINs with other Federal
agencies which are allowed by law, to have these numbers in their own records [Title 26 U.S.C. 7213 and
Title U.S.C. 2018(c)]. Furnishing the information on this form, including your SSN and EIN, is voluntary, but
failure to do so may result in disapproval of this application.
If FNS or the Supplemental Nutrition Assistance Program uses the information furnished on this form for purposes
other than those indicated on the form, it may provide you with an addition statement reflecting those purposes.
Use and Disclosure - We may use computers to check the information you give us against the information kept
by other Federal agencies to ensure that the information you gave us is true, including SSNs and EINs. We will
use the information you give us for managing and enforcing the Supplemental Nutrition Assistance Program laws and rules.
We will also use the information to check on people and meal facilities that we think may be violating Supplemental Nutrition
Assistance
Program laws and rules. We can share SSNs and EINs with the Department of Justice for lawsuits and with the Treasury
Department or other Federal agencies for reporting and collecting monies owed to us, including taking what you owe us out of
future Federal tax refund, Federal salary, or Federal benefit you may receive (7 U.S.C. 2022 and 31 U.S.C. 3711).
The information you give us (except SSNs and EINs) can also be shared with: (1) private collection agencies for
collecting monies owed to us; (2) with local police and Federal and State agencies responsible for enforcing the
Food and Nutrition Act or any other Federal or State laws and rules; and (3) State agencies responsible for the Special
Supplemental Nutrition Program for Women, Infants and Children (WIC).
Penalty Warning Statement - We can deny or take away our approval for you to take Supplemental Nutrition Assistance
Program benefits as payment for food provided in your meal service facility if you: (1) lie or give us untrue information; or (2) try
to hide information we ask you to give us. If you lie, give us untrue information, or hide information from us,
you and the people who own the meal service facility, can be made to pay $10,000 or be put in jail for as
long as five years or both (7 U.S.C. 2024 and 18 U.S.C. 1001).
Certification and Signature - By signing your name on this application, you are telling us that: (1) you are the
meal service principal administrator, executive director, owner or that the meal service owner(s) have asked you
to apply for them; (2) the information you and/or the owner(s) gave us on this form, or papers we asked for,
is true, (3) you have read and understand all the information on this sheet; (4) you understand that you and the
person(s) for whom you are applying are responsible for stopping workers, paid or unpaid, from breaking Supplemental
Nutrition Assistance Program rules such as, but not limited to: (a) trading cash for Supplemental Nutrition Assistance Program
benefits; (b) taking Supplemental Nutrition Assistance Program benefits from people not allowed to use them; (c) taking
Supplemental Nutrition Assistance Program benefits to pay on a credit account or loan; (d) taking Supplemental Nutrition
Assistance Program benefits to pay for items not allowed to be paid for with Supplemental Nutrition Assistance Program benefits;
(e) treating Supplemental Nutrition Assistance Program customers differently than other customers. We can take away a meal
service's right to take Supplemenal Nutrition Assistance Program benefits as payment of food provided at your meal service
facility if any owner(s), manager(s) or anyone working in the meal service violates any of the Supplemental Nutrition Assistance
Program law or rules.
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ATTACHMENT B - continued
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.
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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