Fns 252-r Snap Reauthorization Application For Stores

Form FNS-252-R
US Department of Agriculture
Food and Nutrition Service

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
REAUTHORIZATION APPLICATION FOR STORES

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

Reauthorization Customer Number:
1 Store Name:

1a Is this store still open for business?

2 Store Operations:
2a Is this the current store location? If No, enter current store location address.

Yes

No

Yes

No

Store Location Address (do not enter P.O. Box here):
Street Number:
Street Name:

Additional Address (Bldg #, Unit #, Stall #, etc.):

City:

State:

Zip Code:

2b Do you want to receive official correspondence by email?
If Yes, enter your email address here:____________________________________________
2c Enter the current store telephone number: (

Yes

No

)

2d Store Hours and Days of Operation:
Is this store open 7 days a week, 24 hours per day?
Opening Time

Yes

No

If No, indicate operating hours:

Select AM or PM

Closing Time

Select AM or PM

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
3 How many cash registers are at this store?
4 Total Retail Sales. Enter the actual total retail sales, as reported to IRS, from all products sold at this location. Include all food and non-food sales, for all
forms of payment. (Round sales to nearest dollar. Do not enter cents.) Tax Year: 20

,

$

,

.00

5 Do you stock at least three different items in each of these food categories? Include fresh, frozen, canned, packaged. See instructions for more information.
Breads/Grains

(Examples: bread, cereal, pasta, rice, flour, etc.)

Yes

No

Dairy

(Examples: milk, butter, cheese, yogurt, infant formula, etc.)

Yes

No

Fruits/Vegetables

(Examples: frozen corn, dried beans, applesauce, canned peas, bananas, 100% juice, etc.)

Yes

No

Meat/Poultry/Fish

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

Yes

No

%

5a What percent of your total retail 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 retail 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

7b If Yes, what percent of your total retail sales comes from these non-food and hot food items?

gasoline

hot food

No
other

%

The sum of the three percentage figures above (5a, 6a, 7b) must
equal 100%
FNS-252-R (04-11) Previous Edition Obsolete

SBU

Page 1

Electronic Form Version Designed in Adobe 9.1 Version

8. Owners/Officers. FNS records show the following persons are primary owners or officers of a private corporation that owns the store. In
community property states, the spouse of an owner or officer is also listed. (Community property states are AZ, CA, ID, LA, NM, NV, TX, WA, WI).
Is each person listed still an owner/officer/spouse? Check Yes or No for each person.
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

8a. Are there any primary owners/officers, or their spouses (in community property states), that are not listed here?

If Yes, go to 8b on the Continuation Section to enter information about these persons. See instructions for more information about this question.
I have read, understand and agree with the conditions of participation outlined in the Privacy Act, Use and Disclosure, Penalty Warning
and Certification Statements, and agree to comply with all statutory and regulatory requirements associated with participation in the
Supplemental Nutrition Assistance Program. I am an owner/officer or authorized to complete the application for the store.
Print name:

Business title:
First Name

Signature:

(owner, officer, manager, etc)

Last Name

Middle Name

(

Date:

)
Phone number where you can be reached

CONTINUATION SECTION
8b If you answered Yes to Question 8a, enter information for up to two additional owners/officers/spouses here. Make a copy of this page if you need to
enter additional owner/officer/spouse information, and attach it to this application. Do not enter any information if your store is owned by a publicly-held
corporation or government agency. Do not enter information for persons listed above.
(1) Print name exactly as it appears on the social security card:
First Name:
Street Number:

Middle Name:

Last Name:

Street Name:

Additional Address (Unit #, Suite #, Apt #, etc.):

City:

State:

Social Security Number:

Date of Birth: (MM/DD/YYYY)

/

Business Title (i.e., owner, partner, spouse, etc.):

Last Name:

Street Name:

Additional Address (Unit #, Suite #, Apt #, etc.):

City:
Social Security Number:

If foreign address, add Country:

/

(2) Print name exactly as it appears on the social security card:
First Name:
Middle Name:
Street Number:

Zip Code:

State:
Date of Birth: (MM/DD/YYYY)

/

Zip Code:

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?
If Yes, provide an explanation:

Page 2

Yes

No

KEEP THIS PAGE FOR YOUR RECORDS
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 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 - 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 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 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).
Page 3

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; or am authorized to represent the firm regarding this reauthorization.
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 Use and Disclosure statement.
SNAP training materials are available on request from the Food and Nutrition Service. Owners/Officers must 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.
Violations of program rules can result in administrative actions such as fines, sanctions, withdrawal or disqualification from the
Supplemental Nutrition Assistance Program; Violations of the Supplemental Nutrition Assistance Program rules can also result
in Federal, State and/or local criminal prosecution and sanctions.
Owners/Officers are responsible 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 the firm violates any laws or regulations issued by Federal, State or local agencies, including
civil rights laws and their implementing regulations;
Changes in the firm's ownership, address, type of business and operation must be reported 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.

Page 4

Instructions for Form FNS-252-R
Supplemental Nutrition Assistance Program
Reauthorization Application for Stores
General Instructions
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.
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/retailers and follow the
instructions.
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.
Where to Mail Form FNS-252-R? You must send
Form FNS-252-R to the FNS 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 Office serving your state.

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 publicly-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.

United States Department of Agriculture

Food and Nutrition Service
Question 1 - Store Name: Review the name of your
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 Operations:

Question 2a - 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.
Question 2b - Email Notification: Do you want to
receive official correspondence by email? If Yes, enter
your email address in the space provided.
Question 2c - Store Telephone Number: Enter the
current store telephone number.
Question 2d - Store Hours and Days of Operation:
Check the box to indicate if your store is open 7 days a
week, 24 hours per day. If No, enter the opening and
closing time for each day your store is open for business
and indicate AM or PM.

Question 3 -Number of Cash Registers: Enter

the current number of cash registers at this store. The term
cash registers means all places in the store where you
accept payment.

Question 4 - Total Retail Sales: Enter the total

actual retail sales from everything you sold 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. Include all food, non-food,
and hot food. Include all forms of payment (cash, credit/
debit cards, EBT).

Question 5 - Food Inventory: For each of the food
categories listed check the box 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, and 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 retail 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.

Page 5

CONTINUATION PAGE

Question 6 - Other Foods: Check the box to
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 retail sales that come from the
sale of these food items.
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. Check
Other if you sell items like soap, pet food, paper
products, baby diapers, cleaning supplies, health and
beauty items, etc.
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 retail sales that comes from the sale of
these non-food items and hot foods.
TIP

The sum of percentages entered in Questions
5a, 6a, and 7b must equal 100 percent.

Question 8 - Owner/Officer Information:

All persons currently in FNS files as the primary
owners/officers are listed. Check No, for each person
who is not currently an owner/officer.
The term owner/officer includes owners, officers,
members, partners, and primary shareholders. If this
store owned by a non-profit organization, enter
information for the primary officers. In community
property states it includes spouses. If the store is
owned by publicly-held corporation or government
agency, skip Question 8.
Question 8a - Additional Persons: Are there
persons not listed who are owners/officers, or, in
community property states, spouses? If Yes, go to
the Continuation Section on page 2 to enter
additional persons who are owners/officers or their
spouses.
Question 8b - New Owner, Partner, Officer,
Member, Information: Enter the first name, middle
name, and last name of each added person exactly 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.

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.

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.
Print full name and business title. Sign and date in the
space provided. Provide a phone number where we can
call you if we have questions about the information you
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 time required to complete this information collection
is estimated to average 7.10 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. Instead see the Where to Mail Form
FNS-252-R section of these instructions.
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.

If there are more than two new primary owners/
officers to report, make a copy of the Continuation
Section on page 2 and enter the additional person(s)
information, and attach it to this application. FNS
does not collect information on more than five
primary owners.
Page 6