Supplemental Nutrition Assistance Program - Store Applications

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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: SSN’s 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.

Do you want to receive official correspondence by email? O Yes O No
If Yes, enter owner or store email address:

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How many cash registers at this store?

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Do you stock at least three different types of food items in each of the following food categories on a daily basis?

Examples: Canned meats and fish, ground beef, deli meats, bacon, frozen chicken, eggs, etc.

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