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Form FNS-252
US Department of Agriculture
Food and Nutrition Service
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
APPLICATION FOR STORES
FNS Number
OMB APPROVED NO. 0584-0008
Expiration Date: 07/31/2014
Authorization Initials
Date Authorized
/
FOR FIELD OFFICE USE ONLY
/
FNS Tracking Number
/
1 When did or when will the store open for business under your ownership (MM/DD/YYYY):
/
2 Store Name:
3 Chain Store Number (if applicable):
4 Store Location Address (do not enter P.O. Box here):
Street Number:
Street Name:
Additional Address (Bldg #, Unit #, Stall #, etc.):
City:
State:
Zip Code:
5 Store Mailing Address:
(Skip if your mailing address is the same as your store location. If you have a PO Box address, enter it in the street name field):
Street Number:
Street Name:
Additional Address (Bldg #, Unit #, Stall #, etc.):
City:
State:
6 Store Telephone Number:
(
Zip Code:
If foreign address, add Country:
7 Alternate Telephone Number:
)
(
)
8 Do you want to receive official correspondence by email?
8a If Yes, enter owner or store email address here: _____________________________________________________
9 Is your business a delivery route, farmers' market, farm stand/stall/u-pick, military commissary/exchange or specialty food
store that primarily sells one food type such as meat/poultry, seafood, bread, or fruits/vegetables?
Yes
No
Yes
No
Meat/Poultry Market
Bakery
Military Commissary/Exchange
Farm Stand/Stall/U-Pick
Seafood Market
Produce Market
Delivery Route
Farmers' Market
Do not use this Form FNS-252 if you are applying as a restaurant. Restaurants must use Form FNS-252-2, Application for Meal Services.
10 Type of Ownership (check only one box):
Privately Held Corporation
Sole Proprietorship
Limited Liability Company
Publicly Owned Corporation
Partnership
Nonprofit Cooperative
Government Owned
11 Corporation or Government Agency Information: If privately held corporation or limited liability company, enter the name and address of your
corporation as on record with the State. If government owned, enter the name and address of the responsible government agency. If publicly
owned corporation, enter the name and address of the parent corporate office. All others skip to the next question.
11a Corporation Name:
11b Corporation Address:
Street Number:
Street Name:
Additional Address (Bldg #, Unit #, Stall #, etc.):
City:
State:
11c If publicly owned or government owned, enter a contact person:
Contact Person Name:
Telephone Number:
(
FNS-252 (04-11) Previous Edition Obsolete
)
SBU
Page 1
Zip Code:
If foreign address, add Country:
Email Address:
______________________________________
Electronic Form Version Designed in Adobe 9.1 Version
12 Owner/Officer Information: Enter the name and home address of all officers, owners, partners, and members. You must enter spousal
information for each owner and officer if your business is located in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI). If this is
a public corporation or government owned store, skip to question 13. See instructions for more information about this question.
12a Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:
Last Name:
Street Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Social Security Number:
Date of Birth: (MM/DD/YYYY)
/
Last Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Date of Birth: (MM/DD/YYYY)
/
Additional Address (Unit #, Suite #, Apt #, etc.):
State:
Date of Birth: (MM/DD/YYYY)
/
Zip Code:
If foreign address, add Country:
Business Title (i.e. owner, partner, spouse, etc.):
/
12d Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Last Name:
Street Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
Social Security Number:
Business Title (i.e. owner, partner, spouse, etc.):
Street Name:
Social Security Number:
If foreign address, add Country:
Last Name:
City:
Street Number:
Zip Code:
/
12c Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:
Business Title (i.e. owner, partner, spouse, etc.):
Street Name:
Social Security Number:
If foreign address, add Country:
/
12b Print name exactly as it appears on the social security card:
Middle Name:
First 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.):
/
13 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)?
13a If Yes, provide an explanation:
Yes
No
14 Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
14a If Yes, provide an explanation:
Yes
No
Page 2
15 Do you sell products wholesale to other businesses such as hospitals or restaurants?
15a If Yes, does your retail food sales meet or exceed $250,000 or 50% of your total sales?
16 Does the sale of hot and/or cold freshly prepared foods that are ready-to-eat exceed 50% of your total sales?
Yes
No
Yes
No
Yes
No
17 Total Retail Sales. Enter the total retail sales from all products you sell at this location (both food and non-food products and services). If your store
has been open under your ownership for more than one year, enter actual total retail sales from your most recent IRS tax return for this store (17a),
or if your store has been open under your ownership for less than one year, you must provide estimated sales (17b). If you sell products wholesale
to other businesses, do not include those sales. You must complete either 17a or 17b.
17a Actual Retail Sales:
$
.00
17b Estimated Retail Sales: $
.00
in Tax Year: 20
Day
(check one)
Week
Month
Year
-
17c If you have an Employer Identification Number (EIN) enter it here:
18 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
18a What percent of your total retail sales comes from these food categories?
%
18b Do you stock fresh, frozen or refrigerated foods in at least two of these categories?
19 Do you sell "other" foods, such as snack foods, soft drinks, or condiments?
Yes
No
Yes
No
19a If Yes, what percent of your total retail sales comes from these items?
%
Yes
20 Do you sell non-food items or food that is hot at the time the customer pays for it?
20a If Yes, check the items you carry:
tobacco products
alcohol
lottery
gasoline
hot food
No
other
20b If Yes, what percent of your total retail sales comes from these non-food and hot food items?
%
The sum of the three percentage figures above (18a, 19a, and
20b) must equal 100%
21 How many cash registers are at this store?
22 Is this store open year round?
Yes
No
22a If No, check which month(s) you are open:
Jan
Feb
Mar
Apr
May
23 Is this store open 7 days a week, 24 hours per day?
Jun
Yes
Jul
Aug
Sep
Oct
Nov
No
23a If No, indicate operating hours:
Opening Time
Select AM or PM
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Page 3
Closing Time
Select AM or PM
Dec
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 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 4
CERTIFICATION AND SIGNATURE - By signing below, 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 application may be denied or 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;
By my signature below, I release my tax records to the Food and Nutrition Service;
I will receive Supplemental Nutrition Assistance Program training materials upon authorization. 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 parttime); and that all employees will follow Supplemental Nutrition Assistance Program regulations. If I do not receive these
materials I must contact the Food and Nutrition Service to request them;
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 denied or 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.
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.
X
X
Signature
Print Name
Date Signed
Print Title
MAIL YOUR COMPLETED APPLICATION TO THE FOOD AND NUTRITION SERVICE ADDRESS FOR YOUR STATE
(SEE FIRST PAGE OF INSTRUCTIONS).
Page 5
Instructions for Form FNS-252
Supplemental Nutrition Assistance Program
Application for Stores
Use Form FNS-252, Supplemental Nutrition
Assistance Program Application for Stores to apply
for authorization to participate in the Supplemental
Nutrition Assistance Program.
These instructions should be used when submitting a
paper application by mail to USDA, Food and
Nutrition Service (FNS).
Authorization Processing Time
You must complete the application and submit all the
supporting documents before FNS processes your
application. An incomplete application or failure to
submit documentation will result in a delay. FNS can
take up to 45 days to process a completed application.
The information you provide on the application form
will be used by FNS to determine your store's
eligibility to accept and redeem Supplemental
Nutrition Assistance Program benefits. Your store
may be visited as part of this review. If approved,
your store will be issued a Supplemental Nutrition
Assistance Program license.
!
You must train your employees on the Supplemental
Nutrition Assistance Program rules and regulations.
Training materials are available on our public web
for your convenience and included in your
information packet if FNS approves your application.
You may also obtain training information translated
into other languages from this site.
Do not use this Form FNS-252 if you are applying
as a restaurant. Restaurants must use Form
FNS-252-2, Application for Meal Services.
Contact the FNS Field Office for your state to inquire
about the status of an application.
Specific Instructions
Question 1 - Store Opening Date: Enter the
You must answer all of the questions on the
application form, with the following exceptions:
TIP
CAUTION
You cannot accept Supplemental Nutrition
Assistance Program benefits until you are
authorized and licensed by FNS.
Print or type your answers so they are clear and
legible. Keep a copy of what you submit to FNS for
your records.
Reminders
TIP
Food and Nutrition Service
Apply by Mail: Complete Form FNS-252, attach the
required documents, sign and date the application,
and mail it to the FNS Field Office address for your
state. The FNS Field Office address is listed on the
cover letter that was mailed to you with the
application. You can also find the FNS Field Office
address for your state at: http://www.fns.usda.gov/
snap.
General Instructions
TIP
United States Department of Agriculture
date that the store opened for business or will open
for business under your ownership. You can enter a
future opening date.
If the store is owned by a sole
proprietorship, partnership or nonprofit
cooperative skip question 11.
Question 2 - Store Name: Enter the name
your store is doing business as.
If the store is owned by a privately held
corporation or LLC skip question 11c.
Question 3 - Chain Store Number: Enter
the store number if the store is part of a chain of
stores and you refer to it by a number, i.e., “Fine
Foods #426”. Enter only the number in this field (do
not enter a pound sign).
If the store is owned by a public
corporation or government agency skip
question 12.
Question 4 - Store Location Address:
How to Apply
Enter the store location address. Do not enter a P.O.
Box number here. Use the Additional Address line
for the unit number, building number, stall number,
etc., for addresses with multiple stores at one
location.
You can apply online or submit a paper application
by mail. Use only one method.
Which Filing Method Can I Use?
Apply Online: Go to the USDA, FNS website at:
http://www.fns.usda.gov/snap and follow the
instructions to submit an online application.
Page 6
Question 12 - Owner/Officer Information:
Question 5 - Store Mailing Address: If
Do not complete this question if you indicated the
ownership type is publicly owned corporation or
government owned store in question 10. For all other
ownership types, you must provide information for
all owners, members, partners, primary shareholders
and officers of corporations. In community property
states (AZ, CA, ID, LA, NM, NV, TX, WA, and WI)
spousal information must be entered for each person
listed.
your store has a mailing address that is different than
the location address, enter it here. If you have a P.O.
Box, enter it in the street name field.
Questions 6 - Store Telephone Number:
Enter the store's telephone number, including area
code.
Questions 7 - Alternate Telephone
Number: Enter an alternate telephone number,
For each Owner, Partner, Officer, Member,
Shareholder and Spouse: Enter the first name,
middle name, and last name of each person exactly as
it appears on their social security card. Enter the
home address, social security number and date of
birth for each person.
such as a cellular number, including area code. We
may use the alternate telephone number to your store
during a disaster situation.
Question 8 - Official Correspondence:
Check the block to show if you would like to receive
official correspondence via email.
Question 8a: If Yes, enter the email address where
you want to receive Supplemental Nutrition
Assistance Program information.
If there are more than four primary owners make a
copy of page 2 and enter the additional person(s)
information.
Questions 13 and 14 - License
Denials/Violations, Criminal Convictions:
Question 9 - Special Store Type: Check
Farmers Market if you represent a muti-stall market,
operating at one or more locations, where farmers sell
agricultural products (fruits/vegetables/meats/bread,
etc.,), and you wish to apply for an umbrella
authorization to allow multiple vendors in the market
to accept SNAP benefits.
Check Farm Stand/Stall/U-Pick if you produce and
sell your own agricultural products at a road side
stand, a stall at a market, and/or have a "pick-yourown" operation on your farm.
For each question, check only one box.
Question 13a and 14a: If you answer "Yes" to either
question 13 or 14 provide an explanation.
Question 15 - Wholesale Sales: Check the
box to show if this store sells products to other
businesses (i.e., sells to hospitals, restaurants, etc).
Question 15a: If yes, indicate if your retail food
sales meet or exceed $250,000 or 50% of the store's
total sales.
Question 16 - Hot and/or Cold Freshly
Prepared and Ready-to-Eat Foods: Check
Check Produce Market if you primarily sell fruit/
vegetable items purchased from others, rather than
raised yourself.
the box to show if the sale of hot and/or cold freshly
prepared ready-to-eat foods meet or exceed 50% of
your total sales.
Do not use this Form FNS-252 if you are applying as
a restaurant. Restaurants must use Form FNS-252-2,
Application for Meal Services.
Question 17 - Total Retail Sales: Enter the
Question 10 - Ownership Type: Select the
ownership type that best describes your business.
Question 11 - Corporation or
Government Agency Information:
For privately held corporations and limited liability
companies, enter the name and address that is on
record with the State. For publicly owned
corporations, enter the parent corporation name and
address. For government owned stores, enter the
name and address of the responsible government
agency. For publicly owned corporations or
government owned stores enter the name, telephone
number and email address of the contact person or
the person responsible for the Supplemental Nutrition
Assistance Program license.
Page 7
total retail sales from all products you sell at this
store location. This should include both food and
non-food products and services (e.g., if the store sells
gasoline, include gasoline sales here). If the store has
been in business for at least a year under your
ownership, provide the actual retail sales amount for
this store as reported to the Internal Revenue Service
in question 17a. If the store has been in business
under your ownership for less than a year, you may
enter estimated retail sales for an entire year in
question 17b.
TIP
You must complete either question 17a or
17b, but not both.
Question 21 - Number of Cash Registers:
Question 17a - Actual Retail Sales: Enter the actual
total retail sales amount as reported to the Internal
Revenue Service for this store and the tax year.
Question 17b - Estimated Retail Sales: Enter an
estimated total retail sales amount as a daily, weekly,
monthly, or yearly figure, and check the method that
you used (daily/weekly/monthly/yearly).
Question 17c - Federal Employer Identification
Number (EIN): An EIN is a nine digit number
assigned by the Internal Revenue Service to
businesses for tax filing and reporting purposes. If
you have an EIN number enter it exactly as assigned.
Enter the current number of cash registers at this
store.
Question 22 - Store Open Year Round:
Check the box to indicate if your store is open yearround.
Question 22a: If No, check the boxes next to the
months your store is open for business.
Question 23 - Open 24/7: Check the box to
indicate if your store is open 24 hours a day, 7 days a
week.
Question 23a: If No, enter the opening and closing
time for each day your store is open for business and
indicate AM or PM.
Question 18 - 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 18a - Sales Percent: Enter the percent of
your total retail sales that comes from the sales of
these food items.
Question 18b - Perishables: Check the box that
applies if you stock foods that are fresh, refrigerated
or frozen in at least two of the food categories listed
in question 18.
Privacy Act and Paperwork Reduction
Notice.
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. Instead, see
the How to Apply section.
Question 19 - Other Foods: Check the box to
show if you sell other foods such as snack foods, soft
drinks and/or condiments.
Question 19a: If Yes, enter the percent of your total
retail sales that come from the sales of these food
items.
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.
Question 20 - 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 20a - Items Carried: If Yes, check the
boxes to show which items you sell. Check Other if
you sell items like soap, pet food, paper products,
baby diapers, cleaning supplies, health and beauty
items etc.
Question 20b - Sales Percent: Enter the percent of
your retail total sales that comes from the sales of
these non-food items and hot foods.
TIP
The sum of 18a, 19a and 20b must equal
100 percent.
Page 8
| File Type | application/pdf |
| File Modified | 2012-06-05 |
| File Created | 2012-06-04 |