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pdf United States Department of Agriculture
Food and Nutrition Service
Supplemental Nutrition Assistance Program
Jul 14, 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: 0470683
Farm Test Mart
121314 Sunrise Valley
Herndon, VA 20171
Phone Number: (571) 102 - 2014
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: 0470683
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If I provide false information, my application may be denied or withdrawn;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 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, 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
Mon Jul 14 08:39:31 EDT 2014
United States Department of Agriculture
Food and Nutrition Service
Supplemental Nutrition Assistance Program
Jul 14, 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: 0470683
Farm Test Mart
121314 Sunrise Valley
Herndon, VA 20171
Phone Number: (571) 102 - 2014
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: 0470683
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 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 , 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
Mon Jul 14 08:39:31 EDT 2014
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
APPLICATION FOR STORES
Form FNS-252
US Department of Agriculture
Food and Nutrition Service
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):
02
/
02
/
2014
2 Store Name:
3 Chain Store Number (if applicable):
Farm Test Mart
4
4 Store Location Address (do not enter P.O. Box here):
Street Number:
Street Name:
121314
Additional Address (Bldg #, Unit #, Stall #, etc.):
Sunrise Valley
City:
State:
Zip Code:
Herndon
VA
20171
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:
( 571 ) 102 - 2014
( 571 ) 102 - 2013
8 Owner or Store Email Address:
[email protected]
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
Bakery
Military Commissary/Exchange
✘
✘
Yes
No
Farmers' Market
Direct Marketing Farmer
Seafood Market
Produce Market
Delivery Route
(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):
✘ Sole Proprietorship
Privately Held Corporation
Publicly Owned Corporation
Limited Liability Company
Partnership
Government Owned
Nonprofit Cooperative
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 (07-14) Previous Edition Obsolete
)
SBU
If foreign address, add Country:
Email Address:
-
Electronic Form Version Designed in Adobe 10.0 Version
Page 1
Mon Jul 14 08:39:01 EDT 2014
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:
Last Name:
First Name:
Old
Test
Street Number:
Street Name:
102301
Test Street
Farmer
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Zip Code:
Reston
VA
20190
Social Security Number:
*** - ** - ****
Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.):
11
/ 22
/ 1979
Last Name:
Street Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Social Security Number:
-
-
Zip Code:
/
Last Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
-
-
Zip Code:
Last Name:
Street Name:
Additional Address (Unit #, Suite #, Apt #, etc.):
City:
State:
Social Security Number:
-
-
Zip Code:
Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.):
/
Email Address:
/
12d Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:
If foreign address, add Country:
Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.):
/
Email Address:
/
Street Name:
Social Security Number:
If foreign address, add Country:
Date of Birth: (MM/DD/YYYY) 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:
[email protected]
Owner
12b Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:
If foreign address, add Country:
If foreign address, add Country:
Email Address:
/
13 Answer the questions for all officers, owners, partners, members, and/or managers.
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:
Yes
✘ No
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:
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?
13g If No, provide an explanation:
Yes
No
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?
13i If Yes, provide an explanation:
Yes
✘ No
Page 2
Mon Jul 14 08:39:01 EDT 2014
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?
Yes
✘ No
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?
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
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:
$
17b Estimated Retail Sales:
$
in Tax Year: 20
(check one) ✘ Day
225.00
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.
Yes
✘ No
(Example: milk, butter, cheese, yogurt, infant formula, etc.)
✘ Yes
No
Fruits/Vegetables
(Example: frozen corn, dried beans, applesauce, canned peas, bananas, 100% juice, etc.)
✘ Yes
No
Meat/Poultry/Fish
(Example: canned meats and fish, ground beef, deli meats,bacon, frozen chicken, eggs, etc.)
✘ Yes
No
Breads/Grains
(Example: bread, cereal, pasta, rice, flour, etc.)
Dairy
18a What percent of your total retail sales comes from these food categories?
75
%
✘ Yes
No
19 Do you sell "other" foods, such as snack foods, soft drinks, or condiments?
✘ Yes
No
19a If Yes, what percent of your total retail sales comes from these items?
15
18b Do you stock fresh, frozen or refrigerated foods in at least two of these categories?
✘ 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
gasoline
lottery
✘ hot food
No
other
20b If Yes, what percent of your total retail sales comes from these non-food and hot food items?
10
%
The sum of the three percentage figures above (18a, 19a and
20b) must equal 100%
21 How many cash registers are at this store?
0
22 Is this store open year round?
✘ No
Yes
22a If No, check which month(s) you are open:
✘ May
✘ Apr
✘ Mar
Jan
Feb
✘ Jun
Yes
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:
✘
08:00
✘ Jul
✘ Aug
Sep
Oct
Nov
Dec
✘ No
Closing Time
Select AM or PM
08:00
✘
Tuesday:
Wednesday:
08:00
✘
08:00
✘
08:00
✘
08:00
✘
08:00
✘
08:00
✘
Thursday:
Friday:
Saturday:
Sunday:
24 If you have any 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:
Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text
Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text Test Text
Test Text.
Page 3
Mon Jul 14 08:39:01 EDT 2014
Electronic Application
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 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.
Page 4
Mon Jul 14 08:39:01 EDT 2014
Electronic Application
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 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 Statement s, 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 Jul 14 08:39:01 EDT 2014
| File Type | application/pdf |
| Author | Manmeet Kour |
| File Modified | 2014-07-14 |
| File Created | 2014-07-14 |