FNS-252-FE (farmer Farmers’ Market

United States Department of Agriculture
Food and Nutrition Service
Supplemental Nutrition Assistance Program

May 05, 2014

Mail With Documents
Dear Farmers' Market Applicant:
You must include this cover letter with any documentation you submit to the Food and Nutrition
Service to support your application to accept Supplemental Nutrition Assistance Program (SNAP)
benefits. Failure to do so may result in a delay to your application.
This letter references your following FNS-252E electronic store application:
FNS Number: 0452715
Smith Farms
12345 Hay Road
Ashburn, VA 20148

Phone Number: (703) 231 - 1234
You must submit the following documents to complete your application. Send them to the Food
and Nutrition Service office handling your file at the

‰ Certification and Signature Statement.
‰ Copy of any current business licenses held by the market. If the market does not have any
current business licenses you may skip this requirement.

‰ Copy of photo identification for all responsible officials listed on the application.
‰ Copy of the Social Security number card for all responsible officials listed on the application.
You may check the status of your application online at www.fns.usda.gov/snap. You may also check our
web site to obtain training materials to ensure that you and everyone working at the market understand
the rules and regulations of SNAP. If you have any questions regarding your application, please contact:

USDA, Food and Nutrition Service
PO Box 14500 (USPS Only)
Washington, DC 20044

Phone: (877) 823 - 4369

Sincerely,

USDA, Food and Nutrition Service
Supplemental Nutrition Assistance Program
AN EQUAL OPPORTUNITY EMPLOYER

Electronic Application
Mail With Documents

FNS Number: 0452715
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If I provide false information, my application may be denied or withdrawn;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.
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 as provided above, 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
Page 5

Mon May 05 07:41:42 CDT 2014

United States Department of Agriculture
Food and Nutrition Service
Supplemental Nutrition Assistance Program

May 05, 2014

Keep For Your Records
Dear Farmers' Market Applicant:
You must include this cover letter with any documentation you submit to the Food and Nutrition
Service to support your application to accept Supplemental Nutrition Assistance Program (SNAP)
benefits. Failure to do so may result in a delay to your application.
This letter references your following FNS-252E electronic store application:
FNS Number: 0452715
Smith Farms
12345 Hay Road
Ashburn, VA 20148

Phone Number: (703) 231 - 1234
You must submit the following documents to complete your application. Send them to the Food
and Nutrition Service office handling your file at the

‰ Certification and Signature Statement.
‰ Copy of any current business licenses held by the market. If the market does not have any
current business licenses you may skip this requirement.

‰ Copy of photo identification for all responsible officials listed on the application.
‰ Copy of the Social Security number card for all responsible officials listed on the application.
You may check the status of your application online at www.fns.usda.gov/snap. You may also check our
web site to obtain training materials to ensure that you and everyone working at the market understand
the rules and regulations of SNAP. If you have any questions regarding your application, please contact:

USDA, Food and Nutrition Service
PO Box 14500 (USPS Only)
Washington, DC 20044

Phone: (877) 823 - 4369

Sincerely,

USDA, Food and Nutrition Service
Supplemental Nutrition Assistance Program
AN EQUAL OPPORTUNITY EMPLOYER

Electronic Application
Keep For Your Records

FNS Number: 0452715
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.
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 as provided above, 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
Page 5

Mon May 05 07:41:42 CDT 2014