FNS-252 (REV) SNAP Applications for Stores

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: XX/XX/20XX

Authorization Initials

Date Authorized

/

FOR FNS USE ONLY

/

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:

Zip Code:

If foreign address, add Country:

7 Alternate Telephone Number:

6 Store Telephone Number:
(
)
–
8 Owner or Store Email Address:

(

)

–

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?
Meat/Poultry Market
Seafood Market

No

Farmers' Market

Military Commissary/Exchange
Delivery Route

Bakery
Produce Market

Yes

Direct Marketing Farmer
(Farm Stand/Stall/U-Pick)

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
Publicly Owned Corporation

Sole Proprietorship
Partnership

Limited Liability Company
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:

Zip Code:

11c If publicly owned or government owned, enter a contact person:
Contact Person Name:
Telephone Number:
(

FNS-252 (05-14) Previous Edition Obsolete

)

SBU
Page 1

If foreign address, add Country:

Email Address:

–

Electronic Form Version Designed in Adobe 10.0 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 (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)

Date of Birth: (MM/DD/YYYY)

Zip Code:

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

12d Print name exactly as it appears on the social security card:
Middle Name:
First Name:

City:

Email Address:

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

Social Security Number:

If foreign address, add Country:

Last Name:

Street Name:

City:

Street Number:

Zip Code:

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

12c Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:

Email Address:

Last Name:

Street Name:

Social Security Number:

If foreign address, add Country:

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

12b 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:

13 Answer the questions for all officers, owners, partners, members, and/or managers.
Yes

No

Yes

No

13e Is any officer, owner, partner, and/or member currently receiving SNAP benefits?

Yes

No

13f If Yes, and the store is already operating under this ownership, have the officer, owner, partner, and/or member reported
this income from the store to their SNAP caseworker?

Yes

No

Yes

No

13a Has any officer, owner, partner, member and/or manager ever been 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)?
13b If Yes, provide an explanation:

13c 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?
13d If Yes, provide an explanation:

13g If No, provide an explanation:

13h 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?
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13i If Yes, provide an explanation:

13j Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?
13k If Yes, how many currently authorized stores do you own?

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

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?

Yes
Yes

No
No

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

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:
$
in Tax Year: 20
17b Estimated Retail Sales: $

(check one)

Day

17c If you have an Employer Identification Number (EIN) enter it here:

Week

Month

Year

–

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?
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

Yes

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

Jun

23 Is this store open 7 days a week, 24 hours per day?
23a If No, indicate operating hours:
Opening Time
Select AM or PM
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Yes

Jul

Aug

Sep

Oct

Nov

Dec

No

Closing Time

Select AM or PM

24 If you have additional information or comments you would like to provide to FNS (such as any special circumstances that FNS should know),
please provide the information here:

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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: 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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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 part-time);
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.
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.
X

X
Signature

Print Name

Date Signed

Print Title

MAIL YOUR COMPLETED APPLICATION TO THE RETAILER SERVICE CENTER
(SEE FIRST PAGE OF INSTRUCTIONS).
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Instructions for Form FNS-252
Supplemental Nutrition Assistance Program
Application for Stores
General Instructions

United States Department of Agriculture

Food and Nutrition Service
Authorization Processing Time

Use Form FNS-252, Supplemental Nutrition Assistance
Program Application for Stores to apply for authorization to
participate in the Supplemental Nutrition Assistance Program.

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.

These instructions should be used when submitting a paper
application by mail to USDA, Food and Nutrition Service
(FNS).

!

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.

CAUTION

You cannot accept Supplemental Nutrition Assistance
Program benefits until you are authorized and
licensed by FNS.

Contact the SNAP Retailer Service Center to inquire about the
status of an application.

Specific Instructions

Print or type your answers so they are clear and legible. Keep
a copy of what you submit to FNS for your records.

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.

Question 1 - Store Opening Date: Enter the date that
the store opened for business or will open for business under
your ownership. You can enter a future opening date.

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 2 - Store Name: Enter the name your store is
doing business as.

Question 3 - Chain Store Number: Enter the store

Reminders

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).

You must answer all of the questions on the application form,
with the following exceptions:
TIP

If the store is owned by a sole proprietorship,
partnership or nonprofit cooperative skip question 11.

TIP

If the store is owned by a privately held corporation
or LLC skip question 11c.

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.

TIP

If the store is owned by a public corporation or
government agency skip question 12.

Question 5 - Store Mailing Address: If your store

Question 4 - Store Location Address: Enter the 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.

How to Apply

You can apply online or submit a paper application by mail.
Use only one method.

Questions 6 - Store Telephone Number:

Enter the store's telephone number, including area code.

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.

Questions 7 - Alternate Telephone Number:

Enter an alternate telephone number, such as a cellular
number, including area code. We may use the alternate
telephone number to your store during a disaster situation.

Apply by Mail: Complete Form FNS-252, attach the required
documents, sign and date the application, and mail it to the
SNAP Retailer Service Center. The SNAP Retailer Service
Center address is listed on the cover letter that was mailed to
you with the application. You can also find the SNAP Retailer
Service Center address at: http://www.fns.usda.gov/snap.

Question 8 - Email Address:

Enter the owner or store email address where you want to
receive Supplemental Nutrition Assistance Program
information.

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Question 13i: If you answer "Yes" to question 13h, provide
an explanation.
Question 13k: If you answer "Yes" to question 13j, how
many currently authorized SNAP stores do you own?

Question 9 - Special Store Type: Check Farmers

Market if you represent a multi-stall-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.

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 you answer "Yes" to Question 15, indicate
if your retail food sales meet or exceed $250,000 or 50% of
the store's total sales.

Check Direct Marketing Farmer (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-your- own"
operation on your farm.

Question 16 - Hot and/or Cold Freshly Prepared
and Ready-to-Eat Foods: Check the box to show if the

Check Produce Market if you primarily sell fruit/vegetable
items purchased from others, rather than raised yourself.

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 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.

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.

TIP

You must complete either question 17a or 17b, but
not both.

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.

Question 12 - Owner/Officer Information: 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.
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.

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 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 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.

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

For each question, check only one box.
Question 13b, 13d, and 14a: If you answer "Yes" to either
question 13a, 13c or 14, provide an explanation.
Question 13g: If you answer "No" to question 13f, provide an
explanation.

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Question 19 - Other Foods: Check the box to show if

Question 23 - Open 24/7: Check the box to indicate if

Question 20 - Non-Food/Hot Food: Check the box to

Question 24 - Additional Information or
Comments: Enter any additional information or comments

your store is open 24 hours a day, 7 days a week.
Question 23a: If you answered "No" to Question 23, enter the
opening and closing time for each day your store is open for
business and indicate AM or PM.

you sell other foods such as snack foods, soft drinks and/or
condiments.
Question 19a: If you answered "Yes" to question 19, enter the
percent of your total retail sales that come from the sales of
these food items.

show if you sell any non-food items or food that is hot when
the customer pays for it.
Question 20a - Items Carried: If you answered "Yes" to
question 20, 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.
The sum of 18a, 19a and 20b must equal
TIP
100 percent.

you would like to provide to FNS such as any special
circumstances that FNS should know regarding your store or
this application.

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 the How to
Apply section.

Question 21 - Number of Cash Registers: 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 year-round.
Question 22a: If you answered "No" to question 22, check the
boxes next to the months your store is open for business.

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.

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