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pdf Form FNS-252-R
US Department of Agriculture
Food and Nutrition Service
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
REAUTHORIZATION APPLICATION FOR STORES
OMB APPROVED NO. 0584-0008
Expiration Date: XX/XX/20XX
Reauthorization Customer Number: SM94 2CVV JSU1
PINE PEACE MINI MART
1a Is this store still open for business? ✘ Yes
No
2 Store Operations:
2a Is this the current store location?
If No, enter current store location address.
✘ Yes
No
1 Store Name:
Store Location Address (do not enter P.O. Box here):
Street Number: Street Name:
Additional Address (Bldg #, Unit #, Stall #, etc.):
City:
State:
Zip Code:
2b Owner or Store Email Address:
[email protected]
2c Enter the current store telephone number:
(
876
)
566
–
5458
2d Store Hours and Days of Operation:
✘ Yes
Is this store open 7 days a week, 24 hours per day?
If No, indicate operating hours:
Opening Time
Monday:
Select AM or PM
No
Closing Time
Select AM or PM
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
3 How many cash registers are at this store?
3
4 Total Retail Sales. Enter the actual total retail sales, as reported to IRS, from all products sold at this location. Include all food and non-food sales, for
all forms of payment. (Round sales to nearest dollar. Do not enter cents.)
Tax Year: 20
1 3
Total Retail Sales: $
,
9 9 , 9 9 9 .00
5 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
Dairy
Fruits/Vegetables
(Examples: bread, cereal, pasta, rice, flour, etc.)
(Examples: milk, butter, cheese, yogurt, infant formula, etc.)
(Examples: frozen corn, dried beans, applesauce, canned peas, bananas, 100% juice, etc.)
Meat/Poultry/Fish
(Examples: canned meats and fish, ground beef, deli meats, bacon, frozen chicken, eggs, etc.)
Yes
No
Yes
✘ Yes
✘ Yes
No
No
No
✘
✘
100 %
5a What percent of your total retail sales comes from these food categories?
5b Do you stock fresh, frozen or refrigerated foods in at least two of these categories?
6 Do you sell "other" foods, such as snack foods, soft drinks, or condiments?
Yes
✘ No
Yes
✘ No
0 %
6a If Yes, what percent of your total retail sales comes from these items?
7 Do you sell non-food items or food that is hot at the time the customer pays for it?
7a If Yes, check the items you carry:
tobacco products
alcohol
Yes
lottery
gasoline
hot food
✘ No
other
0 %
7b 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 (5a, 6a, and 7b)
must equal 100%
FNS-252-R (07-14) Previous Edition Obsolete
SBU
Electronic Form Version Designed in Adobe 10.0 Version
2014-07-14 09:12:09 EDT
Page 1
8 Owners/Officers. FNS records show the following persons are primary owners or officers of a private corporation that owns the store. In
community property states, the spouse of an owner or officer is also listed. (Community property states are AZ, CA, ID, LA, NM, NV, TX, WA, WI).
Is each person listed still an owner/officer/spouse? Check Yes or No for each person.
✘
ENAD SHALHOUT
Yes
No
Yes
No
Yes
No
Yes
No
8a Are there any primary owners/officers, or their spouses (in community property states), that are not listed here?
If Yes, go to 8b to enter information about these persons. See instructions for more information about this question.
Yes
✘
No
8b If you answered Yes to Question 8a, enter information for up to two additional owners/officers/spouses here. Make a copy of this page if you need to
enter additional owner/officer/spouse information, and attach it to this application. Do not enter any information if your store is owned by a publiclyheld corporation or government agency. Do not enter information for persons listed above.
(1) Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Last Name:
Additional Address (Bldg #, Unit #,Stall #,etc.):
Street Name:
Street Number:
State:
City:
Social Security Number:
-
Date of Birth:(MM/DD/YYYY)
-
/
Zip Code:
If foreign address,add Country:
Business Title(i.e owner,partner,spouse,etc.): Email Address:
/
(2) Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Last Name:
Additional Address (Bldg #, Unit #,Stall #,etc.):
Street Name:
Street Number:
City:
Zip Code:
State:
Social Security Number:
-
-
Date of Birth:(MM/DD/YYYY)
/
If foreign address,add Country:
Business Title(i.e owner,partner,spouse,etc.): Email Address:
/
9 Answer the questions for all officers, owners, partners, members, and/or managers.
9a Has any officer, owner, partner, member, and/or manager ever had a license 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)?
9b If Yes, provide an explanation:
Yes
✘
No
9c 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?
9d If Yes, provide an explanation:
Yes
✘
No
9e Is any officer, owner, partner, and/or member currently receiving SNAP benefits?
Yes
✘
No
9f If Yes, and the store is already operating under this ownership, have the owner, partner, and/or member reported
this income from the store to their SNAP caseworker?
9g If No, provide an explanation:
Yes
No
9h 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?
9i If Yes, provide an explanation:
Yes
✘ No
9j Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?
9k If Yes, how many currently authorized SNAP stores do you own? 0
Yes
✘
Page 2
No
10 Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
Yes
✘ No
10a If Yes, provide an explanation:
11 What is the Name and Address of the company that provides your EBT equipment and services?
Super EBT
123 Common St.
Springfield, VA 22153
12 If you have additional information or comments you would like to provide to FNS (such as any Store name change, updated mailing address, new
or updated email address for each owner or officer listed in Question 8, or any special circumstances that FNS should know, etc.) please provide
the information here:
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. I am an owner/officer or authorized to complete the application for the store.
Print name:
Explorer
First Name
McCoy
Middle Name
Business title: Other Authorized Representative
(owner, officer, manager, etc.)
Last Name
Signature: Explorer McCoy
Date:
07/14/14
(
123
)
499
–
1239
Phone number where you can be reached
Page 3
KEEP THIS PAGE FOR YOUR RECORDS
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 withdrawal of store
authorization to accept SNAP benefits;
• 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.
KEEP THIS PAGE FOR YOUR RECORDS
CERTIFICATION AND SIGNATURE - By signing the application for reauthorization you are confirming your understanding of and
agreement with the following:
• I am an owner of this firm; or am authorized to represent the firm regarding this reauthorization.
• 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 authorization to accept Supplemental Nutrition Assistance Program (SNAP) benefits may be
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.
• SNAP training materials are available on request from the Food and Nutrition Service. Owners/Officers must 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 SNAP regulations.
• Violations of program rules can result in administrative actions such as fines, sanctions, withdrawal or disqualification from the
Supplemental Nutrition Assistance Program; Violations of the Supplemental Nutrition Assistance Program rules can also result in
Federal, State and/or local criminal prosecution and sanctions.
• Owners/Officers are responsible 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 withdrawn if the firm violates any laws or regulations issued by Federal, State or local agencies, including civil
rights laws and their implementing regulations;
• Changes in the firm's ownership, address, type of business and operation must be reported 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.
| File Type | application/pdf |
| File Modified | 2014-07-14 |
| File Created | 2014-07-14 |