FNS-252-2 SNAP Application for Meal Services

OMB APPROVED NO. 0584-0008
Expiration Date: XX/XX/XXXX

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.
FORM FNS-252-2 (04-11) Previous Editions Obsolete

SBU

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Electronic Form Version Designed in Adobe 9.1 Version

*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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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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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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ATTACHMENT B
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/meal
service providers, 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 and SSNs) 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 (CNA) (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/meal service provider 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/
meal service, 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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ATTACHMENT B - continued
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.

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 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 Adjudication, 1400 Independence Ave, SW, Washington, D.C. 20250-9410.
Do not send the completed application form to this address.

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