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pdf!J.SDA O nline Store Application
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FORM APPROVED OMB No 0584-0008
Exp,rabon Date XX/XX/20XX
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Online Store Application (OSA) for SNAP*
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agen,:'"•as�l'l tnef•CteOIIR�Al:1(15USC 168U(r))orNOtbteolttliOnAl:lof
1982131use 3711(<1)(4})
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NltM of lfM p,K'IOI\ COl'llflltllng 1M lppbcabOII:
-
S81ecl AppllCOIIOO Type
Sales Information
In U'IIS sechon, you 'Wll provide csetaitS regard1t1g ltte market's sales:
Acknowledgement Agreemenl
Basic Information
Does the m.1rket sell products, .;It Whol,ule, to other businuses, such u hospitals or rest..-ur.1nts?
@Yes QNo
Do the m,1rket's annual ret.lil food ules constitute ,1t 1-.ist $250,000 OR 50% of your total gross nles? "Retail s;i.les"
art 3nything other th.1n wholeS3le sales.
@ Yes O No
Do you sell guoline?
Supplemental Information
@Yes O No
Review and Submit
Total Retail Sales
5eleel estimated°' aclual retall saleS If your m.srket h3S been open under your ownership for more than one yur, you must enter
actual toLll reLli1 s.1les from your most recent IRS tax return for this market.If your market has been open under your ownetSl'up f04'
tess U'lan Cf'te yea,. you must prOViOe est.-na1ed saies..
Retail sales are
@ Esttmated O ActUal
Enter the total retail saleS from all pr(liljucts you sell at thiS market (bOth fOOd and nonfOOd prooucts ano services) tr you sea l)(OOucts
wtioleSale to other t>usmesses 00 not i'lduele U'IOSe saleS
Total Ret.-11 S.tlH:
Round to nearest dollar Do not enter a cents or dollar 591 Enter a posiWe numDer less than 999.999,999.999
Eumple: 250,000
00
O Yeal1y O Weekly O Monlhl)' O Darly
E.nter the IOU.ti retail sales: percentage ror eacn saies category fOf products you sell at tnls mancet tocatlOO (e g , If 25� or total retall saies
comes rrom accessory rOOCIS, enter 25% wnere 1ne1ica1ed) tr you dO not sell •ems In a category, enter -o· (e g , If the maneet ooes not
sell nonrooo rtems. enter O} 11 you dO not have tfle actual to1al retail sales: percen1age(s) r0< one or more ot the sales categ<>nes betow
p,ovtde your beSt gooo faith estimate
Round to U'le nearest who4e pe«:er1lage, oo no1 enter a percenl sign Enler a numbef between o ane1 100
Sa�s Cate,gory
%TOt.11
St3.ple FOOd$ (EXampleS rlee, milk beef, appleS, etc)
Accnsory Foods (E)(amptes dups, candy. snack rooos son drlnlCS condiments etc.)
Hot Foods (Examples: hOl coffee, hOl soup. hOt paz:a. etc.)
COIG Foods Pr•�r.d on Site {Only include items intended for 1mmedtate consumpbOl'l or
carry out Example$ sancwlCheS, rresti salads, saJall bars. etc)
Nonfood Items (EXampie:s hOuSehOICI supplies, lObaeCO p
0%
1111
F-OIA I /\C(',esc,1b1hty Statcmcn1 I Pnvac:y Polley I Non D1scnm1n.lhon Statement I Information Quality I tJS/\ gov I White Houc,c
-
Current OSA
screen.
This is the
proposed
OSA screen.
United States Department of Agriculture
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Nov 28, 2018
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| File Type | application/pdf |
| Author | testuser |
| File Modified | 2020-08-31 |
| File Created | 2018-07-18 |