FNS 252FE Supplemental Nutrition Assistance Program Application fo

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May 19, 2017

Mail With Documents
Dear )DUPHUV
0DUNHW$SSOLFDQW
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: 0553978
Osa Test Farmers' Market # 123
1 Maple Street
Reston, VA 22201

Phone Number: (123) 456 - 7890
You must submit the following documents to complete your application. Send them to the Food
and Nutrition Service Rffice handling your file at theDGGUHVVEHORZ

 Certification and Signature Statement.
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You may check the status of your application online at https:// www.fns.usda.gov/snap. You may also check
our website 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,SOHDVHFRQWDFW

86'$Food and Nutrition Service
PO BOX 7228 (USPS Only)
Falls Church, VA 22040

Phone: (877) 823 - 4369
Sincerely,

86'$Food and Nutrition Service
Supplemental Nutrition Assistance Program
AN EQUAL OPPORTUNITY EMPLOYER

Electronic Application
Mail With Documents

FNS Number: 0553978
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If I provide false information, my application may be denied or withdrawn;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

Fri May 19 18:25:18 EDT 2017

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

May 19, 2017

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: 0553978
Osa Test Farmers' Market # 123
1 Maple Street
Reston, VA 22201

Phone Number: (123) 456 - 7890
You must submit the following documents to complete your application. Send them to the Food
and Nutrition Service office handling your file at the address below.

‰ Certification and Signature Statement.
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You may check the status of your application online at https://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 7228 (USPS Only)
Falls Church, VA 22040

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: 0553978
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

Fri May 19 18:25:18 EDT 2017

Form FNS-252
US Department of Agriculture
Food and Nutrition Service

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
APPLICATION FOR STORES

OMB APPROVED No. 0584-0008

Expiration Date: XX/XX/20XX

1 When did or when will the store open for business under your ownership (MM/DD/YYYY):

01 / 01 / 2000
2 Store Name:

Osa Test Farmers' Market
4 Chain Store Number (if applicable):

3 Doing Business As (if different from store name):

123

Alt. Fm Name
5 Store Location Address (do not enter P.O. Box here):
Street Number:
Street Name:

1

Additional Address (Bldg #, Unit #, Stall #, etc.):

Maple St

City:

Reston

State:

Zip Code:

VA

22201

6 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:

123 )

If foreign address, add Country:

8 Alternate Telephone Number:

7 Store Telephone Number:

(

Zip Code:

456 - 7890

(

9 Owner or Store Email Address:

)

-

[email protected]

10 Is your business a delivery route, food buying cooperative, 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
✘ Farmers' Market

Seafood Market

Produce Market

Delivery Route

✘ Yes

No

Food Buying Cooperative

Direct Marketing Farmer (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.
11 Type of Ownership (check only one box):

✘ Sole Proprietorship

Privately Held Corporation
Publicly Owned Corporation

Limited Liability Company

Partnership

Nonprofit Organization

Government Owned

11a Is your firm legally organized as a nonprofit entity?

Yes

✘ No

11b If yes, does your firm have 501(c)(3) nonprofit tax-exempt status?

Yes

✘

No

12 Corporation or Government Agency Information: If privately held corporation, nonprofit organization, 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.

12a Corporation Name:
12b Corporation Address:
Street Number:

Street Name:

Additional Address (Bldg #, Unit #, Stall #, etc.):

City:

State:

Zip Code:

12c If publicly owned or government owned, enter a contact person:
First Name:
Middle Name:

Telephone Number:

(
13

)

If foreign address, add Country:

Last Name:

Email Address:

-

_ - _*******
______
If you have an Employer Identification Number (EIN) enter it here: _**

FNS-252 (MM-YY) Previous Edition Obsolete

SBU
Page 1

Electronic Form Version Designed in Adobe 10.0 Version

14 Owner/Officer Information: Enter the name and home address of all officers, owners, partners, and members. In community property states (AZ, CA,
ID, LA, NM, NV, TX, WA, and WI) spousal information must be entered for each person listed. If this is a publicly owned corporation or
government owned store, skip to question 15. See instructions for more information about this question.
14a Print name exactly as it appears on the social security card:
Middle Name:
Last Name:
First Name:

Jane

D

Street Number:

Street Name:

2

Forrest Street

Doe

Additional Address (Bldg #, Unit #, Stall #, etc.):

City:

State:

Reston

VA

Social Security Number:

01 /

01 /

Owner

1980

14b 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:

City:

State:

Social Security Number:

/

If foreign address, add Country:

Last Name:

Street Name:

Additional Address (Bldg #, Unit #, Stall #, etc.):

City:

State:

Social Security Number:

Zip Code:

If foreign address, add Country:

Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.):

-

/

Email Address:

/

14d Print name exactly as it appears on the social security card:
Middle Name:
First Name:

-

Zip Code:

Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.):

-

Street Number:

If foreign address, add Country:

/

14c Print name exactly as it appears on the social security card:
Middle Name:
First Name:

-

Zip Code:

Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.): Email Address:

-

Street Number:

[email protected]

Additional Address (Bldg #, Unit #, Stall #, etc.):

State:

Social Security Number:

Email Address:

Last Name:

Street Name:

City:

-

If foreign address, add Country:

22201

Date of Birth: (MM/DD/YYYY) Business Title (i.e. owner, partner, spouse, etc.):

*** - ** - ****

Street Number:

Zip Code:

Email Address:

/

15 Answer the questions for all officers, owners, partners, members, and/or managers.
15a Has any officer, owner, partner, member and/or manager ever been denied, withdrawn, disqualified, suspended, or
been fined for Supplemental Nutrition Assistance Program (SNAP), WIC, business, alcohol, tobacco, lottery and/or
health violations?

Yes

✘ No

15c Has 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?
15d If Yes, provide an explanation:

Yes

✘ No

15e Is any officer, owner, partner, and/or member currently receiving assistance through the Supplemental Nutrition
Assistance Program?

Yes

✘ No

15f If Yes, has the officer, owner, partner, and/or member reported this store ownership to their SNAP caseworker?

Yes

No

Yes

✘ No

15b If Yes, provide an explanation:

15g If No, provide an explanation:

15h Has any officer, owner, partner and/or member ever been disqualified from receiving assistance through the
Supplemental Nutrition Assistance Program for an intentional program violation (IPV) or fraud?
Page 2

Fri May 19 18:25:18 EDT 2017

15i If Yes, provide an explanation:

15j Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?

Yes

✘ No

Yes

✘ No

15k If Yes, how many currently authorized stores do you own?

16 Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
16a If Yes, provide an explanation

17 Do you sell products wholesale to other businesses such as hospitals or restaurants?

17a. If Yes, do your retail food sales meet or exceed $250,000 or 50% of your total gross sales?
18 Do you have or are you applying for a restaurant license for your store?
19 Answer 19 a,b,c and d regarding staple food varieties that you have currently and on a continuous basis in your store. Enter
the number of varieties for each staple food category if less than 10. Check "10+" if the number of varieties for each staple
food category is equal to or greater than 10.
19a. Indicate the number of varieties in the Breads and/or Cereals staple food category (Examples: rice, pasta, flour, pita,
tortilla, etc.) that you have currently and on a continuous basis in your store:
19b. Indicate the number of varieties in the Dairy products staple food category (Examples: soymilk, butter, yogurt, infant
formula, etc.) that you have currently and on a continuous basis in your store:
19c. Indicate the number of varieties in the Meat, Poultry, and/or Fish staple food category (Examples: beef, pork, eggs,
tuna, etc.) that you have currently and on a continuous basis in your store:
19d. Indicate the number of varieties in the Vegetables and/or Fruits staple food category (Examples: apple, tomato, peach,
carrot, etc.) that you have currently and on a continuous basis in your store:

✘ Yes

No

✘ Yes

No

✘ Yes

No

3
______
OR
______ OR

10+

✘

7
OR
______
______ OR

10+
10+

✘

10+

20 Answer the following questions regarding stocking units of staple food varieties that you have currently and on a
continuous basis in your store:

✘ Yes

No

✘ Yes

No

✘ Yes

No

✘ Yes

No

21a. Do you have at least one variety of perishable foods in the Breads and/or Cereals category (Examples: bread, pita, etc.)

✘ Yes

No

21b. Do you have at least one variety of perishable foods in the Dairy products category (Examples: refrigerated cow’s milk,
refrigerated butter, etc.)
21c. Do you have at least one variety of perishable foods in the Meat, Poultry, and/or Fish category (Examples: fresh eggs,
frozen chicken, etc.)
21d. Do you have at least one variety of perishable foods in the Vegetables and/or Fruits category (Examples: fresh apples,
frozen broccoli, etc.)

✘ Yes

No

✘ Yes

No

✘ Yes

No

20a. Do you have at least three stocking units of each variety in the Breads and/or Cereals category (Examples: 3 bags of rice,
3 boxes of pasta, etc.)?
20b. Do you have at least three stocking units of each variety in the Dairy products category (Examples: 3 cartons of soymilk,
3 cans of infant formula, etc.)?
20c. Do you have at least three stocking units of each variety in the Meat, Poultry, and/or Fish category (Examples: 3 cans of
tuna, 3 cartons of eggs, etc.)?
20d. Do you have at least three stocking units of each variety in the Vegetables and/or Fruits category (Examples: 3 apples, 3
cans of peaches, etc.)?
21 Answer the following questions regarding perishable foods that you have currently and on a continuous basis in your store:

22 Enter your estimated or actual retail sales for a one year period in the following table. If you do not sell a particular category of
products place a "0" in the appropriate sales column cell.

Select “Actual” or “Estimated” sales below and indicate the tax year corresponding to your sales figures. If your store reported the amount of
sales it made in the last tax year to the Internal Revenue Service (IRS), you must enter actual sales. If your store did not report sales to the
IRS for the last tax year, enter your best good-faith estimate of the sales you expect to take place at your store in the next full tax year.
Estimated Sales

-or- Actual Sales ✘

15
Entered sales figures correspond to tax year 20____

Sales Category
Gasoline
Lottery

Sales
$ 10,000.00
$ 11,000.00

Tobacco (Examples: cigarettes, cigars, chewing tobacco, etc.)

$ 12,000.00
$ 13,000.00

Alcohol (Examples: wine, beer, liquor, etc.)
Other Nonfood (Examples: soap, paper, pet food, etc.)
Hot Foods (Examples: hot coffee, hot soup, hot pizza, etc.)

$ 12,000.00
$ 11,000.00

Cold Prepared Foods (Examples: sandwiches, salads, etc.)
Accessory Foods (Examples: ice cream, potato chips, soda pop, doughnuts, etc.)
Staple Foods (Examples: rice, milk, beef, apples, etc.)
Total Sales
Sales
Total

$ 10,000.00
$ 22,000.00
$ 27,000.00
$ 128,000.00

Page 3

Fri May 19 18:25:18 EDT 2017

0
23 How many cash registers are at this store? ________
24 Are optical scanners used at this store?

Yes

25 Is this store open year round? ✘ Yes

No

25a If No, check which month(s) you are open:
Jan
Feb
Mar
Apr

✘ No

May

Jun

26 Is this store open 7 days a week, 24 hours per day?
✘ Yes
26a If No, indicate operating hours:
Opening Time
Select AM or PM
Monday:

Jul

Aug

Sep

Oct

Nov

Dec

No
Closing Time

Select AM or PM

Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

27 Provide the name and address of the financial institution (bank) that you will be using for SNAP payment deposits:
Financial Institution Name: Bank Name
Financial Institution Mailing Address:
Street Number:

2

Street Name:

Additional Address (Bldg #, Unit #, Stall #, etc.):

Wall st

City:

State:

VA

Arlington

Zip Code:

If foreign address, add Country:

22201

28 If known, provide the name, phone number, and mailing address of the Electronic Benefits Transfer (EBT) equipment provider for your store:

Equipment Provider Name: EBT

Name
123 ) 456 - 7890

Equipment Provider Phone Number: (
Equipment Provider Mailing Address:
Street Number:

5000

Street Name:

Additional Address (Bldg #, Unit #, Stall #, etc.):

crazy st

City:

crazy city

State:

VA

Zip Code:

If foreign address, add Country:

20120

29 Do you have a website for your store? If yes, provide website address:

www.FarmersMarket.com
30 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:

Page 4

Fri May 19 18:25:18 EDT 2017

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. 552 (a)(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.

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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 abc
Print Name

Signature

Spouse

04/04/2017
Date Signed

Print Title
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