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

Reauthorization Customer Number:

1 Store Name:

OMB APPROVED NO. 0584-0008
Expiration Date: XX/XX/20XX

1a Is this store still open for business?

Yes

No

Yes

No

2 Store Operations:
2a Is this the current store location? If No, enter current store location address.
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 Owner or Store Email Address:
2c Enter the current store telephone number:

(

)

–

2d Store Hours and Days of Operation:
Is this store open 7 days a week, 24 hours per day?
If No, indicate operating hours:
Opening Time
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Select AM or PM

Yes

No
Select AM or PM

Closing Time

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

Total Retail Sales: $

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
Dairy
Fruits/Vegetables
Meat/Poultry/Fish

(Examples: bread, cereal, pasta, rice, flour, etc.)
(Examples: milk, butter, cheese, yogurt, infant formula, etc.)
(Examples: frozen corn, dried beans, applesauce, canned peas, bananas, 100% juice, etc.)
(Examples: canned meats and fish, ground beef, deli meats, bacon, frozen chicken, eggs, etc.)

Yes

No

Yes
Yes
Yes

No
No
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?
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

Yes
lottery

gasoline

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

hot food

No

other

%

The sum of the three percentage figures above (5a, 6a, and 7b)
must equal 100%
FNS-252-R (07-14) Previous Edition Obsolete

SBU

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Electronic Form Version Designed in Adobe 10.0 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 to enter information about these persons. See instructions for more information about this question.

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 publiclyheld 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:
Middle Name:
Street Number:

Last Name:

Street Name:

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

City:

State:

Social Security Number:

Date of Birth: (MM/DD/YYYY)

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

City:

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

Email Address:

Last Name:

Street Name:

Social Security Number:

If foreign address, add Country:

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

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

Zip Code:

Zip Code:

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

If foreign address, add Country:
Email Address:

9 Answer the questions for all officers, owners, partners, members, and/or managers.
9a 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 (SNAP), WIC, business, alcohol, tobacco,
lottery, or health license)?

Yes

No

Yes

No

9e Is any officer, owner, partner, and/or member currently receiving SNAP benefits?

Yes

No

9f If Yes, and the store is already operating under this ownership, have the owner, partner, and/or member reported
this income from the store to their SNAP caseworker?

Yes

No

Yes

No

Yes

No

9b If Yes, provide an explanation:

9c Is any officer, owner, partner, member, and/or manager currently or ever been suspended or debarred from conducting
business with or participating in any program administered by the Federal Government?
9d If Yes, provide an explanation:

9g If No, provide an explanation:

9h Has any officer, owner, partner and/or member ever been disqualified from receiving SNAP benefits as a recipient for
an intentional program violation (IPV) or fraud?
9i If Yes, provide an explanation:

9j Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?
9k If Yes, how many currently authorized SNAP stores do you own?
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10 Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
10a If Yes, provide an explanation:

Yes

No

11 What is the Name and Address of the company that provides your EBT equipment and services?

12 If you have additional information or comments you would like to provide to FNS (such as any Store name change, updated mailing address, new
or updated email address for each owner or officer listed in Question 8, or any special circumstances that FNS should know, etc.) please provide
the information here:

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).
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:

Signature:

First Name

Business title:

Last Name

Middle Name

Date:

(

)

(owner, officer, manager, etc.)

–

Phone number where you can be reached

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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 205(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.

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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 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.

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Instructions for Form FNS-252-R
Supplemental Nutrition Assistance Program
Reauthorization Application for Stores
General Instructions

United States Department of Agriculture

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

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.

store as it appears in FNS records.
Question 1a - Store Still in Business: Check Yes or No.
If No, skip Questions 2 through 11. Sign, date, and mail Form
FNS-252-R. Stores not in business will be withdrawn from the
program.
TIP

If the name of the store has changed, make a pen-andink 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.

How to Apply?

Apply Online: If you've been notified to apply online for
reauthorization, follow the instructions on the letter you
received.

Question 2b - Email Address: Enter the owner or store email
address where you want to receive Supplemental Nutrition
Assistance Program information.

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.

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.

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.

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.

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 11;
• If store is owned by a publicly-held corporation or
government agency, skip Question 8.

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).

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.

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 dairy; 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.
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CONTINUATION PAGE

Question 6 - Other Foods: Check the box to show if

Questions 9 and 10 - Ownership Questions:

you sell other foods such as snack food, soft drinks and/or
condiments.

For each question, check only one box.

Question 9b, 9d or 10a: If you answer "Yes" to either
question 9a, 9c or 10, provide an explanation.

Question 6a - Sales Percent: If you answer Yes to question 6,
enter the percent of your total retail sales that come from the
sale of these food items.

Question 9g: If you answer "No" to question 9f, provide an
explanation.
Question 9i: If you answer "Yes" to question 9h, provide an
explanation.

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.

Question 9k: If you answer "Yes" to question 9j, how many
currently authorized SNAP stores do you own?

Question 7a - Items Carried: If you answer Yes to question
7, 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 11 - EBT Provider Information: Enter
the Name and Address of the company that provides your
EBT equipment and services.

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

Question 12 - Additional Information or
Comments: Enter any additional information or comments

you would like to provide to FNS, such as Store name change,
updated mailing address, new or updated email address for
each owner or officer listed in Question 8, or any special
circumstances that FNS should know.

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.

Name and Signature - Before you sign Form FNS-252R, read the attached Privacy Act Statement, Use and
Disclosure Statement, Penalty Warning Statement, and
Certification and Signature Acknowledgment.

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.

Print your 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.

Question 8a - Additional Persons: Are there persons not
listed who are owners/officers, or in community property
states, spouses? If Yes, go to Question 8b to enter additional
persons who are owners/officers or their spouses.

Privacy Act and Paperwork Reduction Notice

Public reporting burden for this collection of information is
estimated to vary from 1 to 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 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 Policy Support, Room
1014, 3101 Park Center Drive, Alexandria, VA 22302, ATTN:
PRA (0584-0008). Do not return the completed form to this
address. Instead, see Where to Mail Form FNS-252-R section
of these instructions.

If there are more than two new primary owners/officers to
report, make blank copies of Question 8b and enter the
additional person(s) information, and attach it to this
application.
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,
date of birth, and business title 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 the store is owned by a publicly-held corporation or
government agency.

To file a complaint of Discrimination, write to the USDA,
Director, Office of Adjudication, 1400 Independence Ave,
SW, Washington, DC 20250-9410. Do not send the completed
application form to this address.

Email Address: Enter the email address from all owners/
officers here (optional).

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