FNS-252-C Application Form (0584-0008) - Corporate Supplemental Application ver 8-2017

OMB APPROVED NO. 0584-0008
Expiration Date: 08/31/2017

Corporate Supplemental Application
(Addendum to Supplemental Nutrition Assistance Program Application for Stores)
FOR FNS USE ONLY

FNS Number

EIN:

Items marked with an asterisk (*) are required.
Centralization Plan Information
*Centralization Plan:
Corporation has no eligible plans.

New Store Information
*Store Name:
Store Number:

Number of Registers:

Optical Scanners:

Store Opened for Business:
Enter future date for a scheduled opening
Month:

Day:

Year:

Enter Estimated Dollar Amounts or Percentages for the following:
Sales Information
*Estimated Annual Retail Sales:

$

*Retail Sales that come from Staple Foods:
(Bread, cereal, dairy, fruits, vegetables, meats, poultry, fish)

%

*Retail Sales that come from Additional Food Types:
(Condiments, spices, coffee, tea, cocoa, candy, cold sandwiches, prepared salads, carbonated/noncarbonated drinks)

%

*Retail Sales from Hot Foods and Non-Food Items:
(Gas, tobacco, alcoholic beverages, lottery tickets, paper, cleaning products)
*Estimated Wholesaler Annual Sales:

FNS-252-C (04-14) Previous Editions are Obsolete

SBU
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%
$

Electronic Form Version Designed in Adobe 9.1 Version

Store Operating Information
Open Year Round?

If not open year round, indicate months store is open below.

Month Open:

Store Open 7 days, 24 hours?
Yes (If yes, skip to On-Site Manager Information section below)

Enter Days Closed:

No

NA

Enter Operating Days and Hours:

On-Site Manager Information

First Name:

Middle Name:

Last Name:

Store Location Address

Street Number:
(e.g. 19023)
Street Name:
Additional Address Information
(stall number, unit number, suite number)
*Country:
*City:

*State:

*Zip Code:

Zip Code + 4:

*County:

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.
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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