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Form FNS-252-R
US Department of Agriculture
Food and Nutrition Service
OMB No. 0584-NEW
Expiration Date XX/XXXX
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
REAUTHORIZATION APPLICATION FOR STORES
Reauthorization Customer Number:
1 Store Name:
1a Is this store still open for business?
2 Is this the current store location?
Yes
No
Yes
No
If No, enter the current store location address (do not enter P.O. Box here)
Street Number:
Street Name:
Additional Address (Bldg #, Unit #, Stall #, etc.):
City:
State:
3 Enter the current store telephone number:
(
)
Zip Code:
-
4 Total Sales. Enter the actual sales from all products you sell at this location, from your most recent IRS tax return for this store. Round to nearest
dollar: $ ______, ______, ______, ______ .00 in tax year: __________.
5 Do you stock at least three different items in each of these food categories?
Breads/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.)
%
5a What percent of your total sales comes from these food categories?
5b Do you stock fresh, frozen or refrigerated foods in at least two of these categories?
6 Do you sell "other" foods, such as snack foods, soft drinks, or condiments?
Yes
No
Yes
No
6a If Yes, what percent of your total sales comes from these items?
%
Yes
7 Do you sell non-food items or food that is hot at the time the customer pays for it?
7a If Yes, check the items you carry:
tobacco products
alcohol
lottery
gasoline
hot food
No
other
7b If Yes, what percent of your total sales comes from non-food and hot food items?
%
The sum of the three percentage figures above (5a, 6a, 7b) must
equal 100%
Owners/Officers. FNS records show the following persons are primary owners or shareholders of a private corporation that owns the store. In
community property states, the spouse of an owner or shareholder is also listed. (Community property states are AZ, CA, ID, LA, NM, NV, TX, WA, WI.)
8 Check No for any person not currently an owner/shareholder.
No
No
No
No
8a Are there persons not listed who are primary owners/shareholders, or, in community property states, spouses?
If Yes, go to Continuation Page to enter information about these persons.
Yes
No
Print the name and business title (i.e., owner, officer, spouse, etc.) of person completing this application for reauthorization on behalf of the store:
First Name
Last Name
Middle Name
Business Title
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 Supplemental Nutrition Assistance Program.
Signature:
FNS-252-R (06-09) Previous Edition Obsolete
Date:
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CONTINUATION PAGE
8b If you answered Yes, to Question 8a, enter information for up to four additional owners/officers here. Do not enter any information or return this page
to FNS if your store is owned by a publicly-held corporation or government agency.
(1) 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:
-
Zip Code:
Date of Birth: (MM/DD/YYYY)
-
/
Last Name:
Street Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Social Security Number:
-
Business Title (i.e., owner, partner, spouse, etc.):
/
(2) Print name as it appears on the social security card:
First Name:
Middle Name:
Street Number:
If foreign address, add Country:
Zip Code:
Date of Birth: (MM/DD/YYYY)
-
/
If foreign address, add Country:
Business Title (i.e., owner, partner, spouse, etc.):
/
(3) 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:
-
Zip Code:
Date of Birth: (MM/DD/YYYY)
-
/
Last Name:
Street Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Social Security Number:
-
Business Title (i.e., owner, partner, spouse, etc.):
/
(4) Print name as it appears on the social security card:
First Name:
Middle Name:
Street Number:
-
If foreign address, add Country:
Zip Code:
Date of Birth: (MM/DD/YYYY)
/
If foreign address, add Country:
Business Title (i.e., owner, partner, spouse, etc.):
/
8c Has any officer, owner, partner, member, and/or manager ever had a license denied, withdrawn or suspended, or been fined for license
violations (i.e., Supplemental Nutrition Assistance Program, WIC, business, alcohol, tobacco, lottery, or health license)?
Yes
No
If yes, provide an explanation:
8d Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
Yes
No
If yes, provide an explanation:
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KEEP THIS PAGE FOR YOUR RECORDS
PRIVACY ACT STATEMENT - Section 9 of the Food and Nutrition Act of 2008, 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 Supplemental Nutrition
Assistance Program (SNAP);
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 Supplemental Nutrition Assistance Program becomes aware of a
violation or possible violation of the Food and Nutrition Act, as explained in the next section called "Use and Disclosure";
Section 278.1(b) of the Supplemental Nutrition Assistance 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 withdrawal of
store authorization to accept SNAP benefits;
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 and Nutrition 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 and Nutrition 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 and Nutrition 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 and Nutrition Act and Supplemental Nutrition Assistance Program regulations.
PENALTY WARNING STATEMENT - The Food and Nutrition Service can deny or withdraw your approval to accept Supplemental
Nutrition Assistance Program 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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KEEP THIS PAGE FOR YOUR RECORDS
CERTIFICATION AND SIGNATURE - By signing the application for reauthorization 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 authorization to accept Supplemental Nutrition Assistance Program (SNAP) benefits may be
withdrawn;
Any information I have provided or will provide may be verified and shared by the USDA with other agencies, as described
in the Privacy Act and Disclosure Statements.
By my signature on the application, I release my tax records to the Food and Nutrition Service;
SNAP training materials are available on request from the Food and Nutrition Service. 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 SNAP regulations.
I am aware that violations of program rules can result in administrative actions such as fines, sanctions, withdrawal or
disqualification from the Supplemental Nutrition Assistance Program; I am aware that violations of the Supplemental Nutrition
Assistance 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 Supplemental Nutrition Assistance 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:
Trading cash for Supplemental Nutrition Assistance Program benefits (i.e., trafficking);
Accepting Supplemental Nutrition Assistance Program benefits as payment for ineligible items;
Accepting Supplemental Nutrition Assistance Program benefits as payment on credit accounts or loans;
Knowingly accepting Supplemental Nutrition Assistance Program benefits from people not authorized to use them;
Disqualification from the WIC Program may result in Supplemental Nutrition Assistance Program disqualification and a
disqualification from the Supplemental Nutrition Assistance 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. Supplemental Nutrition Assistance
Program customers must be treated in the same manner as non-Supplemental Nutrition Assistance Program customers;
Participation can be 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.
Supplemental Nutrition Assistance Program authorization may not be transferred to new owners, partners, or corporations. An
unauthorized individual or firm accepting or redeeming Supplemental Nutrition Assistance Program benefits is subject to substantial
fines and administrative sanctions.
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Electronic Form Version Designed in Adobe 8.1 Version
Instructions for Form FNS-252-R
Supplemental Nutrition Assistance Program
Reauthorization Application for Stores
United States Department of Agriculture
Food and Nutrition Service
General Instructions
Question 1 - Store Name: Review the name of your
Filing Requirements: The Supplemental Nutrition
Assistance Program (SNAP) regulations require the
Food and Nutrition Service (FNS) to periodically
reauthorize stores for continued eligibility. Failure to
cooperate may result in the withdrawal of your store.
The information you provide on the FNS-252-R will
be used by FNS to update our records and determine
your store's continued eligibility to accept SNAP
benefits. FNS may contact you for additional
information or visit your store as part of this review.
store as it appears in FNS records.
Question 1a - Store Still in Business: Check Yes or No.
If No, skip Questions 2 through 8. Sign, date, and mail
Form FNS-252-R. Stores not in business may be
withdrawn from the program.
TIP
If the name of the store has changed, make a
pen-and-ink correction.
Question 2 - Store Address: Check Yes or No
whether the store address is correct. If No, enter the new
address for the store. If you notice a minor error in the
current address, check Yes, but make a pen-and-ink
correction.
Which Filing Method Can I Use?
Choose one of the following methods to apply for
reauthorization.
Apply Online: Once you've been notified that you are
due for reauthorization, you can access the USDA,
FNS website 24 hours a day, 7 days a week at http://
www.fns.usda.gov/snap and follow the instructions.
Question 3 - Store Telephone Number: Enter
the current store telephone number.
Question 4 - Total Sales: Enter the total sales from
everything you sell at this store location as reported to the
Internal Revenue Service in the most recent tax year.
Round to the nearest dollar. Enter the tax year for these
sales.
Apply by Mail: You must complete the
reauthorization application, Form FNS-252-R and
attach any required documents requested by FNS to
the application. Form FNS-252-R is not considered a
valid application unless you sign and date it.
Question 5 - Food Inventory: For each of the food
Where to Mail Form FNS-252-R? You must send
Form FNS-252-R to the FNS Field Office mailing
address listed on the cover letter included with the
paper reauthorization application. You can also check
our website at http://www.fns.usda.gov/snap to find
the FNS Field Office serving your state.
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, 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. For example, the meat/poultry/fish category
would include canned meats and fish, refrigerated lunch
meats, and frozen meats, such as chicken nuggets, as well
as any fresh meats you carry.
Question 5a - Sales Percent: Enter the percent of your
total sales that comes from the sale of these food items.
Question 5b - Perishables: Check the box that applies if
you stock foods that are fresh, refrigerated or frozen in a
least two of the food categories listed in question 5.
Reminders
You must answer all of the questions on Form
FNS-252-R, with the following exceptions:
If the store is no longer in business, skip Questions
2 through 8;
If store is owned by a public-held corporation or
government agency, skip Question 8.
Specific Instructions. This reauthorization
application is pre-printed with information about your
store currently on file with FNS. Review the
preprinted information and check either Yes or No if
the information we have on file is still correct. You
will also be required to give answers about current
store operations. Enter new or changed information in
the spaces provided. Print or type your answers so
they are clear and legible.
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Question 6 - Other Foods: Check the box to
Question 8c and 8d - License denials/violations,
criminal convictions: For each question, check only
one box. If you answer Yes to either question 8c or 8d
provide an explanation.
show if you sell other foods such as snack food, soft
drinks and/or condiments.
Question 6a - Sales Percent: If Yes, enter the
percent of your total sales that come from the sale of
these food items.
Name and Signature - Before you sign Form
FNS-252-R, read the attached Privacy Act Statement,
Use and Disclosure Statement, Penalty Warning
Statement, and Certification and Signature
Acknowledgements.
Question 7 - 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 7a - Items Carried: If Yes, check the
boxes to show which items you sell.
Question 7b - Sales Percent: Enter the percent of
your total sales that comes from the sale of non-food
items and hot foods.
TIP
Print full name and business title. Sign and date in the
space provided. Mail the form in accordance with Where
to Mail Form FNS-252-R section in the General
Instructions.
Privacy Act and Paperwork Reduction
Notice.
The sum of percentages entered in Questions
5a, 6a, and 7b must equal 100 percent.
The time required to complete this information collection
is estimated to average 7 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-NEW) 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 the Where to Mail Form
FNS-252-R section of these instructions.
Question 8 - Owner, Officer, Member,
Shareholder Information: All persons
currently in FNS files as the primary owners/
shareholders are listed. Check No, for each person
who is not currently an owner/shareholder.
The term owner/shareholder includes owners,
members, partners, and officers. In community
property states it includes spouses. If the store is
owned by public-held corporation or government
agency, skip Question 8.
Question 8a - Additional Persons: Are there
persons not listed who are primary owners/
shareholders, or, in community property states,
spouses? If Yes, go to the Continuation Page to enter
additional persons who are owners/shareholders or
their spouses.
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.
Continuation Page
Question 8b - New Owner, Partner, Officer,
Member, Shareholder Information: Enter the first
name, middle name, and last name of each added
person as it appears on their social security card.
Enter the home address, social security number and
date of birth for each added person. In community
property states (AZ, CA, ID, LA, NM, NV, TX, WA,
and WI) spousal information must be entered for
each person listed. Do not enter any information or
return this page to FNS if store is owned by a
publicly-held corporation or government agency.
If there are more than four new primary owners/
shareholders to report, make a copy of the
Continuation Page and enter the additional person(s)
information.
FNS-252-R (06/09) Previous Edition Obsolete
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Electronic Form Version Designed in Adobe 8.1 Version
| File Type | application/pdf |
| File Modified | 2009-07-09 |
| File Created | 2008-10-27 |