SNAP Online Purchasing Pilot

OMB Control No.: 0584-0606

Expiration Date: 03/31/2019

Food and Nutrition Service (FNS) Online Pilot for the

Supplemental Nutrition Assistance Program (SNAP)

Request for Volunteers (RFV) Participation Application Form

INSTRUCTIONS: Please fill out all relevant fields and only leave blank those fields so indicated by the application form instructions contained in the RFV at Section 2.5. Applications with unanswered questions or missing attachments will not be accepted for review and selection. If there is insufficient room to respond or more explanation is needed you may attach additional pages. If you attach additional pages please be sure to indicate that additional information is included elsewhere in the appropriate block of this form and be sure to include the application page and item number on your attachments.

Section A. Identifying Information

A1. Company Name

A2. Website URL Address

A3. Name of Pilot Contact Person

A4. Phone

A5. Email

A6. Address

A7. City

A8. State

A9. ZIP

Section B. Volunteer Business Category and Experience

NOTE: If you have multiple, distinct websites which are eligible for participation in SNAP, each of those websites is considered a separate “FNS retailer” and each will need to obtain a separate FNS authorization to participate in SNAP. This application is limited to only one of your websites.

B1. Which of the following best describes your business? (select one)

◌ National Chain ◌ Regional Chain

◌ Non-Profit Cooperative ◌ Web Only Retailer

◌ Agricultural Producer (explain)

◌ Other (explain)

B2. Do you have multiple websites that may require multiple, separate FNS

authorizations ◌ Yes (explain) ◌ No

All Sales Food Sales

B3a. How many years has your company been in business?

B3b. How many years has your online sales website been in operation?

B3c. Estimated annual number of online transactions in 2015:

B3d. Estimated annual gross online sales value in 2015:

Section C. Website Business Model

C1. What delivery method(s) does your website use? (check all that apply)

 Customer Pickup: Number of Pickup Sites Are all pickup site addresses identified in the system? ◌ Yes ◌ No

 Direct Local Home Delivery by Company Employee

 Commercial Shipping  Other (explain)

C2a. Where does your website fulfill customer orders? (check all that apply)

 Single warehouse  Multiple national warehouses  Multiple regional warehouses

 Single FNS-authorized store  Multiple FNS-authorized stores  Other (explain)

C2b. If you selected any of the three options on the top line of Question C2a, list the city and State of each warehouse.

C3. If you checked multiple fulfillment sites or delivery methods above, do

these all cover the same geographic area and product set? (e.g. if

some of your products are delivered locally and some shipped

nationally, or if different warehouses carry different products,

answer “No” and explain) ◌ Yes ◌ No (explain)

C4a. Does your website allow third parties to sell/ship food products directly

to the customer? ◌ Yes ◌ No (skip to D1)

C4b. Do food sales from your website’s own corporate inventory constitute

more than 50% of all food sales? ◌ Yes ◌ No

C4c. Can you program your website to ensure that only items from your own

corporate inventory can be designated SNAP-eligible? ◌ Yes ◌ No

Section D. SNAP Authorization Status

D1. Identify your business’s SNAP authorization status. (select one and enter relevant information)

◌ Currently Authorized Individual Retailer FNS #

◌ Currently Authorized Chain FNS Corporation # (if known)

◌ Non-Authorized but Eligible Brick and Mortar Retailer ◌ Web Only

◌ Other (explain)

Section E. Website’s Geographic Coverage

E1. Which States are covered by your website? (if “All” not selected, check those that apply) * See Section F

 All	 CO*	 ID*	 LA	 MS	 NJ	 OK	 TN*	 WV*
 AL*	 CT	 IL	 ME	 MO*	 NM*	 OR*	 TX*	 WI*
 AK*	 DE	 IN	 MD	 MT*	 NY	 PA	 UT	 WY*
 AZ*	 FL*	 IA	 MA	 NE*	 NC*	 RI*	 VT*	 DC*
 AR*	 GA	 KS*	 MI	 NV*	 ND*	 SC	 VA	 GU*
 CA*	 HI*	 KY*	 MN	 NH*	 OH	 SD*	 WA*	 VI*

E2a. Do you operate in any States that require your website to collect sales

tax on food products? ◌ Yes ◌ No (skip to E3a)

E2b. List the States that tax all food

E2c. List the States that tax only some food

E2d. Do you use a tax calculation service provider? ◌ Yes ◌ No

E2e. Can you program your website to ensure that items purchased with

SNAP are not taxed? ◌ Yes ◌ No

E3a. Does your website sell any products that require a container deposit? ◌ Yes ◌ No (skip to E4a)

E3b. Do you operate in any States that require your website to collect

container deposits on specific food products? ◌ Yes ◌ No

E3c. Can you program your website to allow payment of deposits required by

State law, but not other deposits, with SNAP benefits? ◌ Yes ◌ No

E3d. Does your website ever have to redeem containers and give deposits back? ◌ Yes ◌ No

E4a. Does your website ever charge any fees for bags or other delivery

Containers due to State or local law or any other reason? ◌ Yes ◌ No (skip to F1a)

E4b. Can you program your website to ensure that fees for bag are not

paid for with SNAP benefits? ◌ Yes ◌ No

Section F. Pilot and Rollout Plan

NOTE: States or territories marked with an asterisk (*) at Question E1 are NOT available for the purposes of this pilot. The State agency must subsequently agree to allow the pilot, so we recommend that you also identify up to two alternative State locations.

F1a. Preferred Initial Area (must be only ONE State or a part of ONE State):

F1b. Alternative initial State(s) or location(s) within those States:

F1c. Rollout Increment 1:

F1d. Rollout Increment 2:

F2a. Will your initial pilot or rollout areas target any specific low-income

populations, food deserts or other vulnerable geographic

locations? ◌ Yes (explain) ◌ No

F2b. Are you partnering with any local government or non-profit groups

for the pilot? ◌ Yes ◌ No (Skip to F3)

F2c. Who are your partners? (identify group name(s) below and attach statement of support from each)

F3. If selected as a pilot participant, how much additional time would you need before you are ready to launch? Take into consideration the time needed to recode the website, institute procedural changes and have legal counsel review the Acculynk contract (provide an estimated timeframe in weeks or months, or a specific estimated readiness date).

Section G. Fee Structure

NOTE: SNAP benefits may only be used to pay for SNAP-eligible food products. SNAP benefits may NOT be used to pay taxes, fees (e.g. delivery, shipping, convenience or service), or any other non-eligible charges. Furthermore, all SNAP authorized retailers are obligated by statute to inform customers, at the time of the order, what fees will be charged and that such fees may not be paid with SNAP benefits; customers must be given the opportunity to cancel an order after being informed of any such fees.

G1. Which of the following types of fees does your website charge? If these fees are fixed, indicate an amount. If fees

are variable, indicate a range. (check all that apply)

 Not applicable $ 0.00  One-time membership fee $

 Fixed handling fee $  Variable handling fee $

 Fixed shipping cost $  Variable shipping cost $

 Fixed delivery fee $  Variable delivery fee $

 Fixed service fee $  Variable service fee $

 No fees for orders over  Annual membership fee $

a certain amount $  Restocking fee for returns $

 Other (explain)

G2. Do you plan to waive or reduce fees for EBT customers? ◌ Yes (explain) ◌ No

G3. Can you program your website to advise customers about all fees

identified by Question H1 before the transaction is processed and offer

customers the opportunity to cancel the order? ◌ Yes ◌ No

Section H. Payment and Processing Methods

H1. Who is your processor for credit transactions?

H2. Which types of tender do you currently accept on your website? (check all that apply)

 Discover  MasterCard  VISA  American Express

 Company Credit Plan  Company Gift Cards  Other Gift Cards

 Other (explain)

H3. Are you willing to accept cash on delivery (COD) for fees? ◌ Yes ◌ No

H4. Can your website accept mixed tender? ◌ Yes ◌ No

H5. Do you also want to accept cash EBT? ◌ Yes ◌ No ◌ Unsure

H6. Will you add commercial PIN debit at the same time as EBT? ◌ Yes ◌ No ◌ Unsure

H7a. Do you accept manufacturers’ coupons on your website? ◌ Yes ◌ No (skip to H8a)

H7b. Do any States require customers to pay tax on savings

from these coupons? (If yes, list States) ◌ Yes ◌ No

H8a. Do you accept store coupons on your website? ◌ Yes ◌ No (skip to H9)

H8b. Are these taxable in the same way as manufacturers’ coupons? ◌ Yes ◌ No (explain)

H9. How do you currently process transactions? (check all that apply)

 Preauthorize sale at checkout and submit for payment once entire order is processed

 Preauthorize sale at checkout and submit each portion of order for payment as it is processed

 Other (explain)

H10a. Do you ever split orders for separate delivery, pickup or

shipping? ◌ Yes ◌ No (skip to I1a)

H10b. Do these split orders ever get processed from separate

warehouses or stores? ◌ Yes ◌ No

H10c. Do you allow split orders to be delivered/shipped

to multiple addresses? ◌ Yes ◌ No (skip to I1a)

H10d. Can you program your website to limit each EBT order

to a single address? ◌ Yes ◌ No

Section I. Non-Profit Cooperatives and Community Supported Agriculture (CSA)

NOTE: If your business is NOT a non-profit cooperative or an agricultural producer that markets

agricultural products directly to consumers through a CSA share arrangement, skip to J1.

I1a. How many pickup dates are there each month overall?

I1b. Are there different pickup days for different distribution sites? ◌ Yes ◌ No

I1c. Do distribution sites have more than one pickup date per month? ◌ Yes ◌ No

I1d. What is the average number of pickup dates per month for each pickup site?

I1e. Can you program your website to ensure that SNAP sales cannot

be performed more than 14 days before the pickup date? ◌ Yes ◌ No

I1f. Can you program your website to inform the customer of the

first date that the sale may be accepted? ◌ Yes ◌ No

Section J. Handling of SNAP-Eligible Foods

J1. Does your website sell any SNAP-ineligible items? ◌ Yes ◌ No (skip to J4a)

J2a. Does your website currently identify which items are SNAP-eligible

and which are not? ◌ Yes ◌ No

J2b. Explain how this is done (or how do you plan to do it).

J2c. If you answered “No” to J2a, how long do you project it will take you to implement this feature? (explain)

J3a Can you program your website to calculate the total value of SNAP- eligible

products (excluding any fees and non-eligible items)? ◌ Yes ◌ No

J3b. Can you limit the maximum amount requested in the SNAP transaction

message to that calculated SNAP subtotal? ◌ Yes ◌ No

J3c. If you responded “No” to question J3a or to question J3b how do you

propose to ensure SNAP benefits are never used to pay for fees or non-

eligible products? (explain)

J4a. Can you program your website to allow the customer to debit less than

the calculated value from SNAP (and use other tender for the balance)? ◌ Yes ◌ No

J4b. Will you support EBT balance inquiry transactions? ◌ Yes ◌ No

J4c. If there are insufficient funds can your system be programmed to display

the customer’s remaining EBT account balances? ◌ Yes ◌ No

J4d. How will your website handle reduced SNAP amounts? (check all that apply)

 System automatically enters remaining SNAP balance as new SNAP amount

 Customer enters a lower specified value (required if previous box is checked)

 Customer “moves” the items from the SNAP subtotal to another tender’s subtotal

 Customer removes items from the basket completely until the SNAP subtotal reaches the desired value

 Other (explain)

Section K. Weighed Products, Substitutions and Out of Stock Items

NOTE: EBT does not support pre-authorization. Because payment is made at the time the order is placed, SNAP customers must receive refunds for any overpayments resulting from underweight products, cheaper substitutions or out of stock items, when the order is finalized. In addition, all EBT purchase transactions require the cardholder to enter a PIN, so price increases resulting from overweight items or more expensive substitutes cannot be completed without the customer present to enter a valid PIN. FNS will allow web retailers to complete an original purchase that includes weighed items using an estimated cost as long as 1) it is padded by no more than 10 percent of the total value of all weighed items; 2) the EBT customer is provided with an advance explanation of this policy; and 3) the total amount of padding is identified to the customer prior to payment. Web retailers may not charge more than the original price if substitutions are made.

K1a. Does your website sell any items by weight? ◌ Yes ◌ No (skip to K2a)

K1b. How does your website currently handle estimated costs for weighed items? (check all that apply)

 No additional charge to the customer for overweight items

 Customer advised that price is estimated and final price may be higher or lower

 Customer provided with a maximum price for final sale

 Total price is padded with a specific percentage (indicate amount) %

 Weighed item subtotal is padded with a specific percentage (indicate amount) %

 Other (explain)

K1c. How does your website currently handle the final price for weighed items? (check all that apply)

 No additional charge to the customer for overweight items

 Customer charged for exact weight of items if under ordered weight

 Customer charged for exact weight of items if over ordered weight

 Other (explain)

K1d. Can you program your website to limit weight padding to no more

than 10% over the total value of the weighed items? ◌ Yes ◌ No

K1e. Can you program your website to advise EBT customers in advance

of weight estimation policies? ◌ Yes ◌ No

K1f. Does your website identify the total amount added to the purchase for

padding and advise the customer before the sale is completed? ◌ Yes (skip to K2a) ◌ No

K1g. Can you program your website to advise EBT customers in advance

of actual amount of weight padding? ◌ Yes ◌ No

K2a. How does your website handle items that are out of stock at the time the order is fulfilled? (check all that apply

and explain where necessary)

 Backorder (How long before a refund is issued?)  Substitution (How are cost differences handled?)

 Refund

K2b. If you checked more than one box for Question K2a, how are decisions made regarding which action to take and how is

the customer notified of the action selected? (explain)

Section L. Order, Refund and Delivery Confirmation and Completion

L1a. What are the delivery methods that you use and the average and maximum delivery times (total days between

transaction approval and customer receipt of goods) for each? (check all that apply)

Average Time Maximum Time

 Direct local home delivery

 Customer pickup

 Commercial shipping from central site(s)

 Other (explain)

L1b. How and to what extent can customers select site, date and time for delivery or pickup? (explain)

L2a. How does your website provide proof of purchase, equivalent to a printed paper receipt, to your customers after

completion of the online order? (check all that apply and attach samples or screenshots of each)

 Confirmation screen  Text (SMS) notification  Email notification

 Retained online order history  Other (explain)

L2b. If your website provides email or SMS notification(s), when does this happen? (check all that apply)

 Immediately after sale  Overnight  Within 24 hours

 When shipped  When processed/fulfilled  Other (explain)

L2c. Do the notifications include details on delivery/pickup date, time and

location? ◌ Yes ◌ No (explain)

L2d. Can you program your website to meet FNS content specifications for

These notices? ◌ Yes ◌ No

L2e. Do you provide an itemized paper receipt at the time of delivery/

pickup/shipping? ◌ Yes ◌ No

L3. Do you provide order/shipment tracking? ◌ Yes (describe) ◌ No

L4. Do you accommodate standing orders (the

same products automatically ordered and

delivered at regular intervals)? ◌ Yes, at reduced price ◌ Yes, at same price ◌ No

L5a. Can you program your order fulfillment process to automatically

calculate and transmit any necessary refunds (e.g. for under

weight or out of stock goods) immediately after order completion? ◌ Yes (skip to L6a) ◌ No

L5b. How will you ensure that customers receive refunds when they are due at order completion? (explain)

L6a. How do you plan to provide proof of pre-delivery refund, including EBT account balances, upon order completion?

(check all that apply and attach samples or screenshots of each, if available)

 Text (SMS) notification  Email notification  Retained online order history

 Include on printed, itemized receipt  Separate printed notification  Other (explain)

L6b. When do you propose to provide the above pre-delivery refund notification?

 Immediately after refund  At time of delivery/pickup/shipping  Other (explain)

L6c. Can you program your website to meet FNS content specifications

for these notices? ◌ Yes ◌ No

L7a. Does your website allow a customer to cancel an order that has

been placed but not yet fulfilled? ◌ Yes ◌ No (skip to M1a)

L7b. How does a customer cancel such an order? (check all that apply)

 Online function  Customer service call  Other (explain)

L7c. Does this require customer authentication or other security? ◌ Yes ◌ No

L7d. How will you ensure that the customer receives a complete refund after cancellation? (explain)

L7e. How is the customer notified of the cancellation? (explain)

L7f. Can you program your website to meet FNS content specifications

for these notices? ◌ Yes ◌ No

Section M. Problem Handling

M1a. For what reasons do you allow food product returns and refunds? (check all that apply)

 We never allow refunds (skip to N1a)  For any reason

 Spoiled or damaged goods  Mistake in the order

 Other (explain)

M1b. Do you require customers who request a

refund to return the product(s)? ◌ Yes ◌ No (skip to M2a) ◌ It depends (explain)

M1c. How may products currently be returned? (check all that apply)

 Website arranges shipping and covers costs  Customer brings items back to an affiliated store

 Customer arranges and pays for shipping  Website arranges shipping deducting costs from

 Website arranges shipping deducting any original refund **

free shipping from refund **  Other (explain)

M1d. If you selected a response in M1c marked with a double asterisk (**): Since the cost of shipping cannot be deducted from SNAP refunds, how would you propose to handle this for a SNAP-only purchase? (explain)

M2a. Is the post-delivery refund process automated? ◌ Yes (skip to M3a) ◌ No

M2b. How will you ensure that customers receive post-delivery refunds when they are due? (explain)

M3a. How is confirmation of a post-delivery refund provided to the customer? (explain)

M3b. Can you program your website to meet FNS content specifications

for these notices? ◌ Yes ◌ No

Section N. Accessibility

N1. How do you plan to educate participating SNAP households about the availability and operation of online purchasing? (explain)

N2. Is your website available in any languages besides English? ◌ Yes (list below) ◌ No

N3. Is your website compliant with the Americans with Disabilities

Act Section 508 accessibility requirements? ◌ Yes ◌ No

Section O. Privacy and Security

O1a. Is any Personally Identifiable Information (PII) such as name, address,

email, etc. retained in your system? ◌ Yes ◌ No

O1b Do customers create stored user accounts? ◌ Yes-Required ◌ Yes-Optional ◌ No

O1c. Does your website’s privacy policy address the following? (check all that apply)

 Internal use of PII data  Sharing of PII with third parties

 Promotional and marketing use of PII  Customer ability to block such use of data

 Exceptions

O1d. Do you ever sell or share detail level PII to third parties not essential

to the sale, delivery or customer service processes? ◌ Yes (explain) ◌ No (skip to O2a)

O1e. Are customers able to opt out of data sharing with third parties? ◌ Yes ◌ No (skip to O2a)

O1f. Explain the opt-out procedures below and provide a link to your online instructions for the process.

O2a. Does your website use cookies? ◌ Yes ◌ No (skip to O3a)

O2b. Is PII ever stored in these cookies? ◌ Yes ◌ No (skip to O3a)

NOTE: Many SNAP customers rely on public computers at places like libraries or schools, so it is important that PII is not

automatically retained on the device used to access your website.

O2c. Can these cookies be easily deleted or avoided? (explain) ◌ Yes ◌ No

O3a. Can customers store credit/debit card data online? ◌ Yes ◌ No (skip to O4)

O3b. Can cardholders opt NOT to store card data online and instead

enter it each time? ◌ Yes ◌ No

O4. Is card number display on screens and in notices always truncated? ◌ Yes ◌ No

O5. Is your website PCI-certified as compliant with their requirements

for protection of “data at rest”? ◌ Yes ◌ No

O6. Please attach a description of the protocols and “best practices” employed by your site to secure data and protect cardholder information. Examples include but are not limited to: tokenization, device fingerprinting (physical, browser version, IP address, mobile app vs. browser), secure firewall technology, minimum browser standards (version, 128-bit encryption, etc.), required use of logon IDs and passwords for website access, strong policies for ID/password format/content and handling of forgotten IDs/passwords, restricted physical access to cardholder data, use of sitekeys or other customer/site authentication, use of commercial security/encryption products, trust seal certification, stringent information security policies for all company and contractor personnel, use and regular update of anti-virus software, etc.

Section P. Website Policies

P1. Please provide a link to or attach a copy of policy statements for each of the following:

Remedies for customer dissatisfaction:

Item returns and refunds:

Non-delivery:

Security:

Privacy:

Section Q. Pilot and SNAP Retailer Application Documentation

NOTE: If you replied “Yes” to Question B2 or “No” to Question C3, you may be required to complete multiple SNAP retailer applications for rollout; however, only one application is required for initial response to the RFV.

Q1. Is your SNAP retailer application attached? ◌ Yes ◌ No (skip to Q3)

Q2. Which application type have you attached? ◌ FNS-252 ◌ FNS-252C ◌ Chain spreadsheet

Q3. Are your photo IDs & SSNs attached? ◌ Yes ◌ No

Q4. Is at least one business permit attached? ◌ Yes ◌ No

Q5. Are copies of your customer notifications attached? ◌ Yes ◌ No

Q6. Is your response to Question O6 attached? ◌ Yes ◌ No

Q7. Are any responses to Question P1 attached? ◌ Yes ◌ No

Q8. Is a continuation document for other questions attached? ◌ Yes ◌ No

Q9. Are any local government or non-profit group statements

of support attached? ◌ Yes ◌ No

Q10. If you answered “No” to Question Q1, Q3, Q4, Q5 or Q6 what are the reasons? (explain)

Section R. Assurances

NOTE: Applicants must respond individually to each of the following assurances. Any qualifications or additional retailer conditions must be identified. A “No” response to any of these assurances will be grounds for non-selection as a pilot participant. Should a “Qualified Yes” explanation result in significant deviation from the intent of the assurance, FNS reserves the right to consider it equivalent to a “No” response. If FNS selects your website for pilot participation, and later determines that you are not in compliance with these assurances, including acceptable qualifications, FNS will provide you written notification to identify the issue and necessary corrective action, which must be implemented within 10 business days. If you fail to remedy the situation within that timeframe, FNS will terminate your authorization as an internet retailer and your participation in the pilot.

R1. We will submit all SNAP and cash EBT purchase and refund ◌ Yes ◌ No ◌ Qualified Yes (explain)

transactions through Acculynk’s PaySecure™.

R2. We will not use the pilot FNS authorization number assigned ◌ Yes ◌ No ◌ Qualified Yes (explain)

to our website for any transactions that do not pass through

Acculynk (i.e. no face-to-face POS transactions in store or

upon delivery)

R3. We agree to negotiate in good faith with Acculynk for contracted ◌ Yes ◌ No ◌ Qualified Yes (explain)

PIN-entry services and pricing and to conform to their

specifications and requirements.

R4. Our website will advise customers of any fees or charges that ◌ Yes ◌ No ◌ Qualified Yes (explain)

are NOT SNAP-eligible and allow customers to opt out of the

purchase before processing.

R5. We agree to the timeframes as specified for customer receipt ◌ Yes ◌ No ◌ Qualified Yes (explain)

of goods purchased and for refunds.

R6. Our website will establish a secure, limited access method for ◌ Yes ◌ No ◌ Qualified Yes (explain)

entry of PINless refunds which conforms to Acculynk’s

specifications.

R7. Except as allowed by waiver, SNAP and cash EBT customers ◌ Yes ◌ No ◌ Qualified Yes (explain)

will receive equal treatment comparable to all other customers.

R8. We agree to the waiver requirements and conditions specified ◌ Yes ◌ No ◌ Qualified Yes (explain)

in the RFV and will sign a written agreement to that effect

prior to authorization as an Internet Retailer.

R9. Our company and website are certified as PCI-compliant and ◌ Yes ◌ No ◌ Qualified Yes (explain)

will remain so as long as we are authorized by FNS. (This will

be validated by Acculynk)

R10. Personal Identification Numbers (PINs) will never be captured ◌ Yes ◌ No ◌ Qualified Yes (explain)

by and/or stored in our own website system.

R11. We accept responsibility for any monetary loss or other damage ◌ Yes ◌ No ◌ Qualified Yes (explain) to EBT customers that results from employee or subcontractor fraud or external hacking resulting from failure to adequately secure our website and databases. We will replace all SNAP benefits that are stolen as a result of such a breach.
R12. Our website will not share any private data with third parties ◌ Yes ◌ No ◌ Qualified Yes (explain) unessential to sale, delivery or customer service for any current or future application or venture without the explicit consent of the EBT customer.
R13. PII data, including card numbers, is, and will only be, entered ◌ Yes ◌ No ◌ Qualified Yes (explain) into our website using secure methods and rigorous firewalls.
R14. We agree to participate in regular periodic conference calls to ◌ Yes ◌ No ◌ Qualified Yes (explain) discuss progress, challenges, and results of the pilot.
R15. We agree to provide copies of the relevant pilot documentation ◌ Yes ◌ No ◌ Qualified Yes (explain) as described in the RFV.
R16. We will adequately test changes made for SNAP online ◌ Yes ◌ No ◌ Qualified Yes (explain) purchasing prior to implementation and will allow FNS to participate in such testing.
R17. We agree to provide the system data, statistics and customer ◌ Yes ◌ No ◌ Qualified Yes (explain) survey responses required by FNS to assess pilot operations to FNS and/or its selected evaluation contractor.
R18. We agree to cooperate with FNS and the evaluation contractor ◌ Yes ◌ No ◌ Qualified Yes (explain) to identify a large enough sample of PIN debit customers to answer research questions designed for the formal evaluation, to obtain their prior informed consent, and to identify appropriate content and format for the required retailer-initiated online survey.
R19. We agree to facilitate access (including updated contact infor­- ◌ Yes ◌ No ◌ Qualified Yes (explain) mation) for evaluation contractor interviews or site visits with retailer staff, evaluation sample PIN debit customers, and other key participants in the demonstration project.
R20. We agree to work in cooperation with FNS and the evaluator ◌ Yes ◌ No ◌ Qualified Yes (explain) to trouble-shoot and resolve issues and refine procedures. .
R21. We agree to make all efforts to maintain the integrity of the ◌ Yes ◌ No ◌ Qualified Yes (explain) evaluation and ensure the quality of the data provided to FNS and the evaluation contractor.
Section S. Privacy Act Statement PRIVACY ACT STATEMENT – Information on this form 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, as explained in the next section called "Use and Disclosure"; Furnishing the information on this form, is voluntary but failure to do so will result in denial of this application; USE AND DISCLOSURE - 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, 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 disclose your information to other Federal and State agencies to verify the information, and to assist in the administration and enforcement of the Food and Nutrition Act as well as other Federal and State laws; 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 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 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 for purposes of administering that Act and the regulations issued under that Act; We may disclose information to the public when a retailer has been disqualified or otherwise sanctioned for violations of the Program after the time for administrative and judicial appeals has expired. This information is limited to the name and address of the store, the owner(s) name(s) and information about the sanction itself. The purpose of such disclosure is to assist in the administration and enforcement of the Food and Nutrition Act and Supplemental Nutrition Assistance Program regulations. PENALTY WARNING STATEMENT - The Food and Nutrition Service can deny or withdraw your approval to accept Supplemental Nutrition Assistance Program benefits if you provide false information or try to hide information we ask you to give us. In addition, if false information is provided or information is hidden from the Food and Nutrition Service, the owners of the firm may be liable for a $10,000 fine or imprisoned for as long as five years, or both (7 U.S.C. 2024(f) and 18 U.S.C. 1001). CERTIFICATION AND SIGNATURE - By signing below, you are confirming your understanding of, and agreement with, the following: I am an authorized respondent to this RFV as defined in the RFV; 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 above; 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; 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; I am responsible for reporting changes regarding any of the policies or assurances I identified above. Supplemental Nutrition Assistance Program authorization may not be transferred to new owners, partners, or corporations. An unauthorized individual or firm accepting or redeeming Supplemental Nutrition Assistance Program benefits is subject to substantial fines and administrative sanctions. I have read, understand and agree with the conditions of participation outlined in the Privacy Act, Use and Disclosure, Penalty Warning and Certification Statements as provided above, and agree to comply with all statutory and regulatory requirements associated with participation in the Supplemental Nutrition Assistance Program.
X___________________________________________ Signature	Print Name
Date Signed	Print Title

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0606. The time required to complete this information collection is estimated to average 20 hours 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.

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