Appendix 5 FNS-252 Supplemental Nutrition Assistance Program Application

FOR\11 APPR��:�; �� xxxx-xxxx
; xx-xx-xxxx

� Online Store Application

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Help

Online Store Application (OSA) for SNAP*
For new applications, select from the following options:

Start New App11ca11on ___.

Contmue Saved Apphcatlon --

For submitted applications, select from the following options:
Note: For tnese actiOns the system may take a few moments to IOad the page(s) you flave setefflllinfM""""-alioftb''t°"'-ID•<·�--•�-O..OK."'°'* .... l'°"ete<-ol\'�lle-----lOtfltt••lle-OI•�- pla,itc1r•nfNS

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-- TIIC�CO',e-\.ellel•�-----..---ro;-1__,,..ns. searching existing data sources. gathenng and maintaining the data

needed. and completmg and revtewmg the coUection of informatK>n. An agency may not conduct or sponsor,

and a person 1s not required to respond to, a collectlon of mformat1on unless it displays a currently valid

0MB control number. send comments regarding this burden estimate or any other aspect of this collectK>n of
information. including suggestK>ns for reducing this burden. to U.S Department of Agnculture. FOod and
NutntK>n service, Office of Policy Support, Room 1014, 3101 Parlc Center Dnve Alexandna, VA 22302, ATTN
PRA (0584-0008) Do not return the completed form to this address
To file a complaint of Discnm,nauon, wnte to the USDA, Director Office of AdJudicatoon, 1400 Independence
Ave, SW, Washington, DC 20250-9410 Do not send the completed applicabon form to this address

II

FOIA I Access1t>1lrty Statement I Pnvac\ Policy I Non 01scnmmat1on Statement 11nformat1on Oualrt). I USA gov I Whrte House

select ApplIcat1on Type

� Print Page

Select an application type to get started

Any firm (except for a Farmers' Marice!) should
complete this application.

Farmers' marlcets are defined as "multi-stall marlcets
at which farmer-producers sell fOod products they
produced (fruits, vegetables, meat, dairy, grains, etc.)
directly to the general public, at a central or fixed
location."

This is the proposed
OSA screen with the
updated address
and burden hour.

0 The folloW1ng apphcabon questions will be tailored towards your above selection

r;:Priva�x A_ct �nd Pa�rwor1c: �eduction N�ticei

Pubhc reporting burden for this collectKm of information IS estimated to vary from 1 to 19 minutes per response
including the tome for revieWing 1nstructK>ns. searching existing data sources. gathenng and maintaining the data

needed. and completmg and revtewmg the coUection of informatK>n. An agency may not conduct or sponsor,

and a person 1s not required to respond to, a collectlon of mformat1on unless it displays a currently valid

0MB control number. send comments regarding this burden estimate or any other aspect of this collectK>n of
information. including suggestK>ns for reducing this burden. to U.S Department of Agnculture. FOod and
NutntK>n service

To file a comp laint of Discnm,nauon, wnte to the USDA, Director Offi ce of AdJudicatoon, 1400 Independence
Ave, SW, Washington, DC 20250-9410 Do not send the completed applicabon form to this address.

II

FOIA I Access1t>1lrty Statement I Pnvac\ Policy I Non 01scnmmat1on Statement 11nformat1on Oualrt). I USA gov I Whrte House

This is the
current OSA
screen with the
old link from
the previous
SNAP website.

Changed the link
on this page to
what’s currently
on the updated
SNAP website.

Proposed OSA Screen - Before You Begin page

setect ApplicaUon Typ e
Before You Begin

Acknowledgement Agreement

� Print Page

Acknowledgement Agreement
PRIVACY ACT STATEMENT - Authority: Section 9 of the Food and Nu1rilion 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(1) of the
Internal Revenue Code of 1986 (26 u.s.c. 6109(1)). authorizes collection of the information on this application
► Details
USE AND DISCLOSURE - Routine Uses: We may use the information you give us in the following ways;
► Details

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(1) 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.

► PRIVACY ACT AND PAPERWORK REDUCTION NOTICE

0 Accept O Decline
Name of the person completing the application:
First Name:

Middle Name:

Last Name:

Title:
Select-One

FOIA I Access1b1lrty Statement I Pnvac\ Polle\ I Non D1scnm1nat1on Statement I Information Quality I USA gov I Whrte House

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�PnnlPage

Acknowledgement Agreement
��Jq.eernert

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IIUINltr$ andrnMUlnlhese l'N,l"l'lll,e, r, her Ne$ fflCI Off( When N s«� d Agrltulw1!: �
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agen,:'"•as�l'l tnef•CteOIIR�Al:1(15USC 168U(r))orNOtbteolttliOnAl:lof
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and NWmon krvice can dffly or 'lrilho�your 'IPPf'O'III
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l'IM infonnmon - Ilk yo-.. to � UI. ln acklitior,, if falM infonn.won is proVllytotll1k>19minutesperN!SJ)OIIM
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� (OMasSIStr,N�anCltfllOtCerraentOl lhefOOClariCI
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sucn reoeraiana sweagencltSbtnt puposeOflOmlnlSltfllgN rooaand MUIIWOnAtl aswttas
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• We m.fmlCIOSentonnabOnlOlhelnll!ffllll R-..eStM::e IOllhepuposeOlrep:,rtlngCltlinquefll
�-��l)t!'IMtS01S600orl'l"IOfe10tWJ1aUOnStOll'fflll\leClurlOefll\eSNo'IP we
wil�eatl'l�otbtlOllel�RitvetMseswe on Form 10!D-C (c..:MabOl'IOIDl!bl)
Wt .. 1eQ011t11tseoeDtio10lhelnttrNll�SflA/ltelol'\Cllet"lhelUIIIOnl'j011"1elt'ltomeTu
R�( 26CFRPIM1and6 02)Ul'ldtfs«ti01'16050POlll'ltlnlffllal�CO!St(26USC

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ProgramlOl'WDfl'ltn. wants. allCICNlart'fl (WIC).aullOflZf!CI lllOef sec110n 170ftheCIIICIMUlrllonAt10f
1966(CNA)(42USC 1186) IOIIJlA'poM50 f�IMlAtt and lhtregulal0nslSsuedurlOef!Ml

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• Ol!Kk;isu'ts�I05USC �al(t1X12) wtmiylll,(lo,eJlli;IITMIQn lO'tonwnerrep;wUng
agen,:'"•as�l'l tnef•CteOIIR�Al:1(15USC 168U(r))orNOtbteolttliOnAl:lof
1982131use 3711(<1)(4})
• Weffla,/CIIICI05e�IONpubllc'llnt:nalfl\lllerl'l.llbtfflCll$QIJllillef aomlnlSlfa!Mlana J!dtlal awe• l 'laSeJIJll(ea TM
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FOOClll'ICINulrWlonAcl a'IC�NI.CrllaOnAHiSl.lnc.tP!ogrlm�

NltM of lfM p,K'IOI\ COl'llflltllng 1M lppbcabOII:

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� Print Page

Select Application Type

Basic Information

Before You Begin

In this section, provide basic store information. Use the Help feature if you have any questions.
Acknowledgement Agreement
Bas,c Information
Ownership Information

When did or when will the store open for business under your ownership?
mmddyyyy

Store Name

Sales Information
Inventory Information

If different from your Store Name, what is the Legal Business Name for your store? What is this?

Supplemental Information
Review and Submit

Chain Store Number: What is this?

What is your store's location address? (do not enter PO Box here)
Street Number:

Street Name:

Additional Address Line:

City:

State:

Zip Code:

Select-One

Is the store's mailing address the same as the store's location address?
• Yes

No

Store Telephone Number:

Alternate Telephone Number: What is this?

Owner or Store Email Address:

Confirm Email Address:

Is your business any one of the following: a delivery route; food buying cooperative; farmers' market; farm
stand/stall/u-pick; military commissary/exchange; or a specialty food store that primarily sells one food type
such as meat/poultry, seafood, bread, or fruits/vegetables?
Yes

• No

Save and Continue Later

51-§1
FOIA I Access1b1hty Statement I Pnvacy Policy I Non-D1scnm1nat1on Statement I Information Quality I USA gov I White House

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USDA

Online

'OQ.MAOPROVEDCMB No �� �o:

Store ApplicaUon

�rJ:t:,n D.iH? u u ,:w;

ft Home

Acknowledgement Agroomoot

�
Inventory lnformdtJOn
Suppktmenlal lnformat10n
Review end Submit

• EstJmate<:1 0 Actual
Enter the total retail sales from al produCtS you sell at thlS stc:we (botn rood •nd nontood products Wld semces) 1f you set produCts
Wnotiesale to OOlef �ses
not WdJOe tnose sales

oo

Round to nea� dolal Do noc enter a �s or dollar sign Enter a pos«Ne number �s tnan 999 999 999 999
Example: 250,000

00

O v._ O WttlflY O -.tnlY O oaor
Enter the total retalll sates percentage ror each sales category for products you set al ttus store k>ClllJOn (e g , 25"- Of lOtal retalll sates
c:ornes rrom ac:c:e,ory JooFile Typeapplication/pdfAuthorZachary FurcoloFile Modified2020-08-31File Created2018-07-18