FNS 252-C Corporate Supplemental Application (addendum to Suppleme

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

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
CORPORATE MULTI-STORE APPLICATION

OMB APPROVED NO. 0584-0008
Expiration Date: 01/31/2021

Part A - Corporate Application
1

Is your business a delivery route, a 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
Seafood Market

Bakery
Produce Market

Delivery Route

Farmers' Market

Military Commissary/
Exchange

Direct Marketing Farmer
(Farm Stand/Stall/U-Pick)

Yes

No

Food Buying
Cooperative

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.
2

3

Type of Ownership (check only one box):
Privately Held Corporation
Publicly Owned Corporation

Sole Proprietorship
Partnership

2a

Is your firm legally organized as a nonprofit entity?

2b

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

Yes

3a

Corporation Name:

3b

Corporation Address:

3c

State:

Zip Code:

If publicly owned or government owned, enter a contact person:
Telephone Number:
Contact Person Name:
)

If foreign address, add Country:

Email Address:

–

Enter Employer Identification Number (EIN):
–
Do you have a website for your store? If yes, provide website address:
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 publicly
owned corporation or government owned store, skip to question 7. See instructions for more information about this question.
Print name exactly as it appears on the social security card:
Middle Name:
Last Name:
First Name:
Street Number:

Street Name:

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

City:

State:

Social Security Number:
6b

No

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

(

6a

Yes

Street Name:

City:

6

No

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.

Street Number:

4
5

Nonprofit Organization

Limited Liability Company
Government Owned

Date of Birth: (MM/DD/YYYY)

Social Security Number:

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

Date of Birth: (MM/DD/YYYY)

FNS-252C (06-17) Previous Edition Obsolete

Email Address:

Last Name:

Street Name:

City:

If foreign address, add Country:

Business Title (i.e. owner, partner, spouse, etc.):

Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:

Zip Code:

Zip Code:

Business Title (i.e. owner, partner, spouse, etc.):

SBU
Page 1

If foreign address, add Country:
Email Address:

Electronic Form Version Designed in Adobe 10.0 Version

6c

Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:

Street Name:

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

City:

State:

Social Security Number:
6d

Last Name:

Date of Birth: (MM/DD/YYYY)

Social Security Number:

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

Date of Birth: (MM/DD/YYYY)

Email Address:

Last Name:

Street Name:

City:

If foreign address, add Country:

Business Title (i.e. owner, partner, spouse, etc.):

Print name exactly as it appears on the social security card:
Middle Name:
First Name:
Street Number:

Zip Code:

Zip Code:

Business Title (i.e. owner, partner, spouse, etc.):

If foreign address, add Country:
Email Address:

7 Answer the questions for all officers, owners, partners, members, and/or managers.
Yes

No

Yes

No

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

Yes

No

7f
7g

If Yes, has the officer, owner, partner, and/or member reported this store ownership to their SNAP caseworker?
If No, provide an explanation:

Yes

No

7h

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?

Yes

No

7i

If Yes, provide an explanation:

7j
7k

Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?
If Yes, how many currently authorized stores do you own?

Yes

No

Yes

No

7a

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?

7b

If Yes, provide an explanation:

7c

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?

7d

If Yes, provide an explanation:

7e

8 Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
8a If Yes, provide an explanation:

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Part B - Complete Part B for each location under your ownership applying for SNAP authorization.
Copy Part B pages as needed.
1 Does this location sell products wholesale to other businesses such as hospitals or restaurants?
1a If Yes, do retail food sales at this location meet or exceed $250,000 or 50% of total gross sales for the location?

Yes
Yes

No

2 Do you have or are you applying for a restaurant license for this location?

Yes

No

No

3 When did or when will the store open for business under your ownership (MM/DD/YYYY)?
4 Store Name:

5 Chain Store Number (if applicable):

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

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

City:

State:

Zip Code:

8 Alternate telephone number:
(
)
–

7 Store telephone number:
(
)
–
9 Owner or Store Email Address:

10 Answer 10 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.
10a Indicate the number of varieties in the Breads and/or Cereals staple food category (Examples: rice, pasta, flour, pita, tortilla,
10+
OR
etc.) that you have currently and on a continuous basis in your store:
10b Indicate the number of varieties in the Dairy products staple food category (Examples: soymilk, butter, yogurt, infant
10+
OR
formula, etc.) that you have currently and on a continuous basis in your store:
10c Indicate the number of varieties in the Meat, Poultry, and/or Fish staple food category (Examples: beef, pork, eggs, tuna,
10+
OR
etc.) that you have currently and on a continuous basis in your store:
10d Indicate the number of varieties in the Vegetables and/or Fruits staple food category (Examples: apple, tomato, peach,
10+
OR
carrot, etc.) that you have currently and on a continuous basis in your store:
11 Answer the following questions regarding stocking units of staple food varieties that you have currently and on a continuous basis in your store:
11a 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.)?
11b Do you have at least three stocking units of each variety in the Diary products category (Examples: 3 cartons of
soymilk, 3 cans of infant formula, etc.)?
11c 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.)?
11d 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.)?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

12 Answer the following questions regarding perishable foods that you have currently and on a continuous basis in your store:
12a Do you have at least one variety of perishable foods in the Breads and/or Cereals category (Examples: bread,
pita, etc.)?
12b Do you have at least one variety of perishable foods in the Diary products category (Examples: refrigerated
cow's milk, refrigerated butter, etc.)?
12c Do you have at least one variety of perishable foods in the Meat, Poultry, and/or Fish category (Examples: fresh
eggs, frozen chicken, etc.)?
12d Do you have at least one variety of perishable foods in the Vegetables and/or Fruits category (Examples: fresh
apples, frozen broccoli, etc.)?

13 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

Entered sales figures correspond to tax year 20

Sales Category
Gasoline
Lottery
Tobacco (Examples: cigarettes, cigars, chewing tobacco, etc.)
Alcohol (Examples: wine, beer, liquor, etc.)
Other Nonfood (Examples: soap, paper, pet food, etc.)
Hot Foods (Examples: hot coffee, hot soup, hot pizza, etc.)
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
Page 3

Sales
$
$
$
$
$
$
$
$
$
$

14 How many cash registers are at this store?
15 Are optical scanners used at this store?

Yes

No

Yes
16 Is this store open year round?
No
16a If No, check which month(s) you are open:
Jan
Feb
Mar
Apr
May
Jun
17 Is this store open 7 days a week, 24 hours per day?
17a If No, indicate operating hours:
Opening Time
Select AM or PM
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Yes

Jul

Aug

Sep

Oct

Nov

Dec

No
Select AM or PM

Closing Time

18 Provide the name and address of the financial institution (bank) that you will be using for SNAP payment deposits:
18a Financial Institution Name:
18b Financial Institution Mailing Address:
Street Number: Street Name:
City:

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

Zip Code:

If foreign address, add Country:

19 If known, provide the name, phone number, and mailing address of the Electronic Benefits Transfer (EBT) equipment provider for your store:
19a Equipment Provider Name:
19b Equipment Provider Phone Number:
(

)

–

19c Equipment Provider Mailing Address:
Street Number:
City:

Street Name:

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

Zip Code:

If foreign address, add Country:

20 If you have 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:

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Part C - Privacy Act Statement, Use and Disclosure
The following statements apply to the information supplied in Part A. Corporate Application and in Part B. Store Application. Keep this 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 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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Part D - CERTIFICATION AND SIGNATURE - By signing below, you are confirming your understanding of and agreement with the
following for the Corporation and all stores for which the Corporation is applying for participation.
• I am an owner/officer of this firm or authorized to act on behalf of the 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, the firm's application for the Corporation and for Store locations 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 the firm's 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 part-time); 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, at all locations authorized under the firm's ownership. 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 for the Corporation and any or all locations if the 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, store locations, 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

SUBMIT YOUR COMPLETED APPLICATION (Parts A, B, and D) TO THE FOOD AND NUTRITION SERVICE.

Page 6

Privacy Act and Paperwork Reduction Notice
Public reporting burden for this collection of information is estimated to vary from 1 to 19 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, follow the instructions provided by your FNS
representative. 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.

Page 7