Form FNS 252-E FNS 252-E SNAP Online Store Application

PRIVACY ACT STATEMENT – Authority: Section 9 of the Food and Nutrition Act of 2008, as amended, (7 U.S.C. 2018):
section 405(c) 2) (C) of the Social Security Act (42 U.S.C 405(c)(2)(C); and section 6109(f) of the Internal Revenue Code of
1986 (26 U.S.C. 6109(f), 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;
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 of 2008, 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
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 – Routine Uses: 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, and whether arising by general statute, or by
regulation, rule, or order issued pursuant thereto, 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 information to other Federal and State agencies to verify the information reported by applicants
and participating firms, 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 (excluding EINs) 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 the Internal Revenue Service, for the purpose of reporting delinquent retailer and
wholesaler monetary penalties of $600 or more for violations committed under the SNAP. We will report each
delinquent debt to the Internal Revenue Service on Form 1099-C (Cancellation of Debt). We will report these
debts to the Internal Revenue Service under the authority of the Income Tax Regulations (26 CFR Parts 1 and
602) under section 6050P of the Internal Revenue Code (26 U.S.C 6050P);
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 (CAN) (42
U.S.C. 1786), for purposes of administering that Act and the regulations issued under that Act;
Disclosures pursuant to 5 U.S.C. 55 2a(b) (12). We may disclose information to “consumer reporting agencies” as
defined in the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or the Debt Collection Act of 1982 (31 U.S.C.
3711(d)(4));
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.

(con’t next page)

Do you stock at least three different types of food items in each of the following categories on a daily basis? Include
fresh, frozen, canned, packaged.

Fruits/Vegetables (fresh, canned/packaged, or frozen)
(Example: frozen corn, dried beans, applesauce, canned peas, bananas, 100% juice, etc.)
Meat/Poultry/Fish (fresh, canned, refrigerated, frozen)

(Example: canned meats and fish, ground beef, deli meats, bacon, frozen chicken, eggs,
etc.)