Form FNS 252 FNS 252 SNAP Application for Stores (English)

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:01/312021

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

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

4 Chain Store Number (if applicable):

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

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

City:

State:

Zip Code:

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:

Zip Code:

7 Store Telephone Number:

If foreign address, add Country:

8 Alternate Telephone Number:

(
)
–
9 Owner or Store Email Address:

(

)

–

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
Seafood Market

Bakery
Produce Market

Military Commissary/Exchange

Farmers' Market

Delivery Route

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.
11 Type of Ownership (check only one box):
Privately Held Corporation
Sole Proprietorship
Limited Liability Company
Nonprofit Organization
Publicly Owned Corporation
Partnership
Government Owned
11a Is your firm legally organized as a nonprofit entity?
11b If yes, does your firm have 501(c)(3) nonprofit tax-exempt status?

Yes
Yes

No
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:
Contact Person Name:
Telephone Number:
(

)

If foreign address, add Country:

Email Address:

–

13 If you have an Employer Identification Number (EIN), enter it here:

FNS-252 (06/17) Previous Edition Obsolete

SBU
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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. 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 15. See instructions for more information about this question.

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

Last Name:

Street Name:

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

City:

State:

Social Security Number:

Date of Birth: (MM/DD/YYYY)

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

City:

State:
Date of Birth: (MM/DD/YYYY)

Date of Birth: (MM/DD/YYYY)

Zip Code:

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

Date of Birth: (MM/DD/YYYY)

Email Address:

Last Name:

Street Name:

Social Security Number:

If foreign address, add Country:

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

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

City:

Email Address:

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

Social Security Number:

If foreign address, add Country:

Last Name:

Street Name:

City:

Street Number:

Zip Code:

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

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

Email Address:

Last Name:

Street Name:

Social Security Number:

If foreign address, add Country:

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

14b 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:

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

No

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

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?
15b If Yes, provide an explanation:

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:

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?
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15i If Yes, provide an explanation:

15j Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?
15k If Yes, how many currently authorized stores do you own?

Yes

No

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

Yes

No

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?

Yes
Yes

No
No

18 Do you have or are you applying for a restaurant license for your store?

Yes

No

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:

OR

10+

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:

OR

10+

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:

OR

10+

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:

OR

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:
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.)?

Yes

No

Yes

No

Yes

No

Yes

No

Yes
Yes

No
No

Yes

No

Yes

No

21 Answer the following questions regarding perishable foods that you have currently and on a continuous basis in your store:
21a Do you have at least one variety of perishable foods in the Breads and/or Cereals category (Examples: bread, pita, etc.)?
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.)?
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

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
$
$
$
$
$
$
$
$
$
$

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
25a If No, check which month(s) you are open:
Jan
Feb
Mar
Apr
May
26 Is this store open 7 days a week, 24 hours per day?
26a If No, indicate operating hours:
Opening Time
Select AM or PM
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

No
No
Jun

Jul

Yes

Aug

Sep

Oct

Nov

Dec

No

Closing Time

Select AM or PM

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

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

Zip Code:

If foreign address, add Country:

28 If known, provide the name, phone number, and mailing address of the Electronic Benefits Transfer (EBT) equipment provider for your store:
28a Equipment Provider Name:
28b Equipment Provider Phone Number:
28c Equipment Provider Mailing Address:
Street Number:
City:

Street Name:

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

Zip Code:

If foreign address, add Country:

29 Do you have a website for your store? If yes, provide website address:
30 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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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 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. 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

MAIL YOUR COMPLETED APPLICATION TO THE RETAILER SERVICE CENTER (SEE FIRST PAGE OF INSTRUCTIONS).

Page 6

Instructions for Form FNS-252
Supplemental Nutrition Assistance Program
Application for Stores
General Instructions

United States Department of Agriculture

Food and Nutrition Service
Authorization Processing Time

Use Form FNS-252, Supplemental Nutrition Assistance
Program Application for Stores to apply for authorization to
participate in the Supplemental Nutrition Assistance Program
(SNAP).

You must complete the application and submit all the
supporting documents before FNS processes your application.
An incomplete application or failure to submit documentation
will result in a delay.

These instructions should be used when submitting a paper
application by mail to USDA, Food and Nutrition Service
(FNS).

!

CAUTION

The information you provide on the application form will be
used by FNS to determine your store's eligibility to accept and
redeem SNAP benefits. Your store may be visited as part of
this review. If approved, your store will be issued a SNAP
license.

You cannot accept Supplemental Nutrition Assistance
Program benefits until you are authorized and
licensed by FNS.

Contact the SNAP Retailer Service Center to inquire about the
status of an application.

Specific Instructions

Print or type your answers so they are clear and legible. Keep
a copy of what you submit to FNS for your records.

You must train your employees on the SNAP rules and
regulations. Training materials are available on our public
website for your convenience and included in your
information packet if FNS approves your application. You
may also obtain training information translated into other
languages from this site.

Question 1 - Store Opening Date: Enter the date that
the store opened for business or will open for business under
your ownership. You can enter a future opening date.
Question 2 - Store Name: Enter the name of your
business.

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.

Question 3 - Doing Business As: If you are doing

business under a name that is different from the store name
you entered, please provide this name in question 3.

Reminders

You must answer all of the questions on the application form,
with the following exceptions:

Question 4 - Chain Store Number: Enter the store
number if the store is part of a chain of stores and you refer to
it by a number, i.e., “Fine Foods #426”. Enter only the number
in this field (do not enter a pound sign).

• Question 3.
• If the store is owned by a sole proprietorship or partnership,
skip question 12.

Question 5 - Store Location Address: Enter the store

location address. Do not enter a P.O. Box number here. Use
the Additional Address line for the unit number, building
number, stall number, etc., and for addresses with multiple
businesses at one location.

• If the store is owned by a privately held corporation or LLC
skip question 12c.
• If the store is owned by a public corporation or government
agency skip question 14.

Question 6 - Store Mailing Address: If your store

has a mailing address that is different than the location
address, enter it here. If you have a P.O. Box, enter it in the
street name field.

How to Apply

You can apply online or submit a paper application by mail.
Use only one method.

Questions 7 - Store Telephone Number: Enter the
store's telephone number, including area code.

Which Filing Method Can I Use?

Apply Online: Go to the USDA, FNS website at:
https://www.fns.usda.gov/snap and follow the instructions to
submit an online application.

Questions 8 - Alternate Telephone Number: Enter
an alternate telephone number, such as a cellular number,
including area code. We may use the alternate telephone
number to contact you during a disaster situation. The
alternate telephone cannot be the same as the store telephone
number.

Apply by Mail: Complete Form FNS-252, attach the required
documents, sign and date the application, and mail it to the
SNAP Retailer Service Center. The SNAP Retailer Service
Center address is listed on the cover letter that was mailed to
you with the application. You can also find the SNAP Retailer
Service Center address at: https://www.fns.usda.gov/snap.

Question 9 - Email Address: Enter the owner or store

email address where you want to receive Supplemental
Nutrition Assistance Program information.

Page 7

Question 10 - Special Store Type: Check Produce

Questions 15 and 16 - Ownership Questions: For

Market if you primarily sell fruit/vegetable items purchased
from others, rather than raised yourself.
Check Farmers Market if you represent a multi-stall market,
where farmers sell their own agricultural products (fruits/
vegetables/meats/bread, etc.) directly to the public.
Check Direct Marketing Farmer (Farm Stand/Stall/U-Pick) if
you produce and sell your own agricultural products at a road
side stand, a stall at a market, and/or have a "pick-your- own"
operation on your farm.
Check Food Buying Cooperative if you are a private nonprofit
association of consumers whose members pool their resources
to buy food.
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.

each question, check only one box.

Question 15b, 15d, and 16a: If you answer "Yes" to either
question 15a, 15c or 16, provide an explanation.
Question 15g: If you answer "No" to question 15f, provide an
explanation.
Question 15i: If you answer "Yes" to question 15h, provide
an explanation.
Question 15k: If you answer "Yes" to question 15j, enter the
number of currently authorized SNAP stores under your
ownership.

Question 17 - Wholesale Sales: Select "Yes" or "No"

to indicate if your store sells products to other businesses (i.e.,
sells to hospitals, restaurants, etc.).
Question 17a: If you answer "Yes" to question 17, indicate if
your retail food sales meet or exceed $250,000 or 50% of your
store's total gross sales.

Question 11 - Ownership Type: Select the ownership
type that best describes your business.
Question 11a: select “yes” or “no to indicate if you are legally
organized as a nonprofit entity.
Question 11b: select “yes” or “no” to indicate if you have
501(c)(3) non-profit tax-exempt status.

Question 18 - Restaurant license: Select “Yes” or

“No” to indicate if you have or are applying for a restaurant
license for your store.

Question 19-21: Staple Food Varieties & Depth
of Stock: Please answer the questions regarding staple food

Question 12 - Corporation or Government
Agency Information: For privately held corporations,

varieties and the depth of stock that you have currently and on
a continuous basis in your store. Additional information
related to staple food varieties and minimum stocking
requirements can be found online at: https://
www.fns.usda.gov/snap/retailers-store-traininginformation.

nonprofit organizations, and limited liability companies, enter
the name and address that is on record with the State. For
publicly owned corporations (also referred to as publicly
traded corporations), enter the parent corporation name and
address. For government owned stores, enter the name and
address of the responsible government agency. For publicly
owned corporations or government owned stores enter the
name, telephone number and email address of the contact
person or the person responsible for the Supplemental
Nutrition Assistance Program license.

For each question, check only Yes or No.
Staple Foods: Staple food means those food items intended
for home preparation and consumption in each of the
following food categories: meat, poultry, or fish; bread or
cereals; vegetables or fruits; and dairy products. A list of
examples of staple foods can be found online at: https://
www.fns.usda.gov/snap/retailers-store-traininginformation.

Question 13 - Federal Employer Identification
Number (EIN): An EIN is a nine digit number assigned

by the Internal Revenue Service to businesses for tax filing
and reporting purposes. If you have an EIN number enter it
exactly as assigned.

Variety: Variety means different kinds of products in each of
the four staple food categories. A list of examples of
acceptable varieties in each of the staple food categories can
be found online at: https://www.fns.usda.gov/snap/retailersstore-training-information.

Question 14 - Owner/Officer Information: Do not

complete this question if you indicated the ownership type is
publicly owned corporation (i.e., publicly traded corporation)
or government owned store in question 11. For all other
ownership types, you must provide information for all owners,
members, partners, primary shareholders and officers of
corporations, including entities with non-profit status. In
community property states (AZ, CA, ID, LA, NM, NV, TX,
WA, and WI) spousal information must be entered for each
person listed.
For each Owner, Partner, Officer, Member, Shareholder
and Spouse: Enter the first name, middle name, and last name
of each person exactly as it appears on their social security
card. Enter the home address, social security number and date
of birth for each person.
Email Address: Enter the email address from all owners/
officers here (optional).
If there are more than four primary owners make a copy of
page 2 and enter the additional person(s) information.

Stocking Unit: A stocking unit is a can, bunch, box, bag, or
package for the product as typically sold. A list of examples of
stocking units can be found online at: https://
www.fns.usda.gov/snap/retailers-store-traininginformation.
Perishable Foods: Perishable foods are items which are either
frozen staple food items or fresh, unrefrigerated or refrigerated
staple food items that will spoil or suffer significant
deterioration in quality within 2-3 weeks.

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Question 22 - Retail Sales: Enter the total retail sales
for each kind of products you sell at this store location (e.g., if
the store sells gasoline, enter gasoline sales where indicated).
If you do not sell items in a category, enter “0” (e.g., if the
store does not sell alcohol, enter 0). If the store has been in
business for at least a year under your ownership, provide the
actual retail sales amount for this store. If the store has been in
business under your ownership for less than a year, enter
estimated retail sales for a full year.

Question 28 - EBT Equipment: If you have already
selected the Electronic Benefit Transfer equipment provider
for your store, please enter the provider name, address and
phone number.
Question 29 - Store Website: If you have a public
website for your store, please enter the full website address.
Question 30 - Additional Information or
Comments: Enter any additional information or comments

Exclude any wholesales. If you answered yes to question 17,
FNS may contact you for further information about the dollar
amount of wholesales.

you would like to provide to FNS such as any special
circumstances that FNS should know regarding your store or
this application.

Accessory Food Items: Snacks and desserts, such as potato
chips and ice cream, are not considered staple foods. Spices,
most beverages, seasonings, and other food items that
complement or supplement meals are also not considered
staple foods. These products are considered accessory food
items. While still eligible for purchase with SNAP benefits,
accessory food items do not count towards Criteria A or B. A
full list of accessory foods can be viewed at: https://
www.fns.usda.gov/snap/retailers-store-traininginformation.

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, see the How to
Apply section.

Staple Foods: See information about staple foods in the
instructions for questions 19-21.
Total Sales: Enter the sum of the retail sales for all the
products listed above it.

Question 23 - Number of Cash Registers: Enter the

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.

current number of cash registers at this store used for
accepting payment for retail purchases.

Question 24 - Optical Scanners: Select "Yes" or "No"
to indicate if optical scanners are used at your store.

Question 25 - Store Open Year Round: Select
"Yes" or "No" to indicate if your store is open year-round.
Question 25a: If you answered "No" to question 25, check the
boxes next to the months your store is open for business.

Question 26 - Open 24/7: Select "Yes" or "No" to
indicate if your store is open 24 hours a day, 7 days a week.

Question 26a: If you answered "No" to question 26 enter the
opening and closing time for each day your store is open for
business and indicate AM or PM.

Question 27- Financial Institution Name and
Address: Provide the name and address of the financial
institution that you will be using for SNAP payment deposits
(i.e. what is your bank?).

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