Appendix 7 - FNS 2 Supplemental Nutrition Assistance Program Application

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

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
REAUTHORIZATION APPLICATION FOR STORES

Reauthorization Customer Number:

2 Legal Business Name (if different
from Store Name):

1 Store Name:

OMB APPROVED NO. 0584-0008
Expiration Date: XX/XX/XXXX

3 Is this store still open for business?
Yes

No

Yes

No

4 Store Operations: [Store Address]
4a Is this the current store location? If No, enter current store location address.
Store Location Address (do not enter P.O. Box here):
Street Number: Street Name:

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

City:

State:

Zip Code:

4b Owner or Store Email Address:
4c Enter the current store telephone number:

(

)

5 Store Hours and Days of Operation:
Is this store open 7 days a week, 24 hours per day?
If No, indicate operating hours:
Opening Time
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Select AM or PM

6 How many cash registers are at this store?

4d Alternate telephone number:

–
Yes

(

)

–

No
Closing Time

Select AM or PM

7 Are optical scanners used at this store?

Yes

No

8 Answer the following questions 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.
8a 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:
8b

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+

8c

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+

8d

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+

9 Answer the following questions regarding stocking units of staple food varieties that you have currently and on a continuous basis in your store:
9a Do you have at least three stocking units of at least three varieties in the Breads and/or Cereals category (Examples: 3
Yes
bags of rice, 3 boxes of pasta, 3 packages of bread, etc.)?

No

9b

Do you have at least three stocking units of at least three varieties in the Dairy products category (Examples: 3 cartons of
soymilk, 3 cans of infant formula, 3 packages of cheese, etc.)?

Yes

No

9c

Do you have at least three stocking units of at least three varieties in the Meat, Poultry, and/or Fish category (Examples: 3
cans of tuna, 3 cartons of eggs, 3 packages of ground beef, etc.)?

Yes

No

9d

Do you have at least three stocking units of at least three varieties in the Vegetables and/or Fruits category (Examples: 3
apples, 3 cans of peaches, 3 packages of lettuce, etc.)?

Yes

No

Yes

No

10b Do you have at least one variety of perishable foods in the Dairy products category (Examples: refrigerated cow’s milk,
refrigerated butter, etc.)?

Yes

No

10c Do you have at least one variety of perishable foods in the Meat, Poultry, and/or Fish category (Examples: fresh eggs,
frozen chicken, etc.)?

Yes

No

10d 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

10 Answer the following questions regarding perishable foods that you have currently and on a continuous basis in your store:
10a Do you have at least one variety of perishable foods in the Breads and/or Cereals category (Examples: bread, pita, etc.)?

FNS-252-R (08-20) Previous Editions Obsolete

SBU
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Electronic Form Designed in AEM Version 6.4

11 Total Retail Sales: Enter the total retail sales from all products you sell at this location (both food and nonfood products and services) and indicate
the tax year corresponding to your sales figures. If you sell products wholesale to other businesses, do not include those sales.
Total Retail Sales:

in tax year 20

11a Enter the total retail sales percentage for each sales category for products you sell at this store location (e.g., if 25% of total retail sales comes
from accessory foods, enter 25% where indicated). If you do not sell items in a category, enter "0" (e.g., if the store does not sell nonfood items,
enter 0). If you do not have the actual total retail sales percentage(s) for one or more of the sales categories below, provide your best good faith
estimate.
Sales Category

% Total

Staple Foods (Examples: rice, milk, beef, apples, etc.)
Accessory Foods (Examples: chips, candy, snack foods, soft drinks, condiments, etc.)
Hot Foods (Examples: hot coffee, hot soup, hot pizza, etc.)
Cold Foods Prepared on Site (Only include items intended for immediate consumption or carryout. Examples:
sandwiches, fresh salads, salad bars, etc.)
Nonfood Items (Examples: household supplies, tobacco products, gasoline, alcohol, pet foods, lottery, etc.)
Total Sales Percentage (total must equal 100%)
11b Do you sell gasoline?

Yes

No

12 Owners/Officers. FNS records show the following persons are primary owners or officers of a private corporation that owns the store. Is each
person listed still an owner/officer? Check Yes or No for each person. Spousal information is no longer required for businesses located in community
property states. If a spouse of an owner or officer is listed and this person is not an owner or officer, check "No" for that person.
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

12a Are there any primary owners/officers that are not listed here?
If Yes, go to 12b to enter information about these persons. See instructions for more information about this question.

12b If you answered Yes to question 12a, enter information for up to two additional owners/officers here. Make a copy of this page if you need to
enter additional owner/officer information, and attach it to this application. Do not enter any information if your store is owned by a publicly-held
corporation or government agency. Do not enter information for persons listed above.
(1) Print name exactly as it appears on the social security card:
First Name:
Middle Name:
Street Number:

Last Name:

Street Name:

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

City:

State:

Social Security Number:

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 (owner, partner, etc.):

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

Zip Code:

Zip Code:

If foreign address, add Country:

Business Title (owner, partner, etc.):

Email Address:

13 Answer the questions for all officers, owners, partners, members, and/or managers.
13a 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

Yes

No

13b If Yes, provide an explanation:

13c 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?
13d If Yes, provide an explanation:

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13e Is any officer, owner, partner, and/or member currently receiving assistance through the Supplemental
Nutrition Assistance Program?

Yes

No

13f If Yes, has the owner, partner, and/or member reported this store ownership to their SNAP caseworker?

Yes

No

Yes

No

Yes

No

Yes

No

13g If No, provide an explanation:

13h 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?
13i If Yes, provide an explanation:

13j Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?
13k If Yes, how many currently authorized SNAP stores do you own?
14 Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?
14a If Yes, provide an explanation:

15 What is the name, phone number, and address of the company that provides your EBT equipment and services?
Equipment Provider Name:
Equipment Provider Phone Number:
Equipment Provider Mailing Address:
Street Number:

Street Name:

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

City:

State:

Zip Code:

If foreign address, add Country:

16 Provide the name and address of the financial institution (bank) that you use for SNAP payment deposits:
Financial Institution Name:
Financial Institution Mailing Address:
Street Number:

Street Name:

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

City:

State:

Zip Code:

If foreign address, add Country:

17 Do you have a website for your store? If yes, provide website address:
18 If you have additional information or comments you would like to provide to FNS (such as any store name change, updated mailing address, new or
updated email address for each owner or officer listed in question 12, or any special circumstances that FNS should know, etc.), please provide the
information here:

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 fail to disclose required/requested information. 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.
Printed Name:

Signature:

First Name

Business Title:

Last Name

Middle Name

Date:

(

)

(owner, officer, manager, etc.)

–

Phone number where you can be reached

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KEEP THIS PAGE 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 Food and Nutrition Service in the administration of the SNAP;
• 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 SNAP 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 each owner's 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, ITIN, and EIN, is voluntary but failure to do so will result in withdrawal of store
authorization to accept SNAP benefits;
• 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, ITINs, 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, ITINs, 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, ITINs, 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, ITINs, 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 1099C (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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KEEP THIS PAGE FOR YOUR RECORDS
CERTIFICATION AND SIGNATURE - By signing the application for reauthorization you are confirming your understanding of and agreement with the
following:
• I am an owner of this firm; or am authorized to represent the firm regarding this reauthorization.
• 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 authorization to accept Supplemental Nutrition Assistance Program (SNAP) benefits may be 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.
• SNAP training materials are available on request from the Food and Nutrition Service. Owners/Officers must 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 SNAP
regulations.
• Violations of program rules can result in administrative actions such as fines, sanctions, withdrawal or disqualification from the Supplemental
Nutrition Assistance Program; Violations of the Supplemental Nutrition Assistance Program rules can also result in federal, state and/or local
criminal prosecution and sanctions.
• Owners/officers are responsible for violations of the Supplemental Nutrition Assistance Program regulations, including those committed by any of
the firm's employees, 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. SNAP customers must be treated in the same manner as non-Supplemental
Nutrition Assistance Program customers;
• Participation can be withdrawn if the firm violates any laws or regulations issued by federal, state, or local agencies, including civil rights laws and
their implementing regulations;
• Changes in the firm's ownership, address, type of business, and operation must be reported to the Food and Nutrition Service.
• If your store is disqualified or fined for violating Program rules, FNS may publicly disclose your store's name and address, owners' names, and the
penalty.
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.

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

If No, skip questions 4 through 18. Sign, date, and mail Form
FNS-252-R. Stores not in business will be withdrawn from the
program.
TIP

If the name of the store has changed, make a pen-andink correction.

Question 4 - Store Operations:

Question 4a - Store Address: Check Yes or No whether the
store address is correct. If No, enter the new address for the
store. If you notice a minor error in the current address, check
Yes, but make a pen-and-ink correction.

How to Apply?

Apply Online: If you've been notified to apply online for
reauthorization, follow the instructions on the letter you received.

Question 4b - Email Address: Enter the owner or store email
address where you want to receive Supplemental Nutrition
Assistance Program official correspondence.

Apply by Mail: You must complete the reauthorization
application, Form FNS-252-R and attach any required documents
requested by FNS to the application. Form FNS-252-R is not
considered a valid application unless you sign and date it.

Question 4c - Store Telephone Number: Enter the current
store telephone number.
Question 4d - 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 number cannot be the same as the store telephone
number.

Where to Mail Form FNS-252-R? You must send Form
FNS-252-R to the FNS mailing address listed on the cover letter
included with the paper reauthorization application.

Reminders

You must answer all of the questions on Form FNS-252-R, with
the following exceptions:

Question 5 - Store Hours and Days of Operation:

Check the box to indicate if your store is open 7 days a week, 24
hours per day. If No, enter the opening and closing time for each
day your store is open for business and indicate AM or PM.

• Question 2;
• If the store is no longer in business, skip questions
4 through 18;
• If store is owned by a publicly-held corporation or
government agency, skip question 12.

Question 6 - Number of Cash Registers: Enter the

Specific Instructions. This reauthorization application is
pre-printed with information about your store currently on file
with FNS. Review the preprinted information and check either
Yes or No if the information we have on file is still correct. You
will also be required to give answers about current store
operations. Enter new or changed information in the spaces
provided. Print or type your answers so they are clear and legible.
as it appears in FNS records and enter the most commonly
referred to name of your business (e.g., the doing business as
name, trade name, etc.). If the most commonly referred to name
of your business is the same as what is currently displayed for
Question 1, keep the pre-filled store name as is.

Food and Nutrition Service
Question 3 - Store Still in Business: Check Yes or No.

Filing Requirements: The Supplemental Nutrition Assistance
Program (SNAP) regulations require the Food and Nutrition
Service (FNS) to periodically reauthorize stores for continued
eligibility. Failure to cooperate may result in the withdrawal of
your store. The information you provide on the FNS-252-R will
be used by FNS to update our records and determine your store's
continued eligibility to accept SNAP benefits. FNS may contact
you for additional information or visit your store as part of this
review.

Question 1 - Store Name: Review the name of your store

United States Department of Agriculture

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

Question 7 - Optical Scanners: Select "Yes" or "No" to

indicate if optical scanners are used at your store.

Question 8-10: Staple Food Varieties & Depth of
Stock: Please answer the questions regarding staple food

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/

retailer/training.

For each question, check only Yes or No.

Question 2 - Legal Business Name: If your legal

business name (e.g., Joe's Enterprise, LLC) is different from your
store name, enter it in question 2.

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CONTINUATION PAGE

Question 12 - Owner/Officer Information: All

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/retailer/training.

persons currently in FNS files as the primary owners/officers
are listed. Check No, for each person who is not currently an
owner/officer.

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/retailer/training.

The term owner/officer includes owners, officers, members,
partners, and primary shareholders. Spousal information is no
longer required for businesses located in community property
states (AZ, CA, ID, LA, NM, TX, WA, and WI). If this store
is owned by a non-profit organization, enter information for
the primary officers. If the store is owned by a publicly-held
corporation or government agency, skip question 12.

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/retailer/training.

Question 12a - Additional Persons: Are there persons not
listed who are owners/officers? If Yes, go to question 12b to
enter additional persons who are owners/officers or their
spouses.

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.

If there are more than two new primary owners/officers to
report, make blank copies of question 12b and enter the
additional person(s) information, and attach it to this
application.

Question 11 - Retail Sales: Enter the total retail sales for

Question 12b - New Owner, Partner, Officer, Member,
Information: 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, (or individual
tax identification number, as an alternative to SSNs), and date
of birth for each person, and business title for each added
person. Do not enter any information or return this page to FNS
if the store is owned by a publicly-held corporation or
government agency.

each kind of product you sell at this store location as reported to
the Internal Revenue Service in the most recent tax year. Enter
the tax year for these sales.
Question 11a: If you do not sell items in a category, enter
"0" (e.g., if the store does not sell gasoline, enter 0).
Question 11b: Gasoline Sales: Select "Yes" or "No" to
indicate if your store sells gasoline.

Email Address: Enter the email address for all owners/officers
here (optional).

Hot Foods and Cold Foods Prepared on Site: Total retail
sales percentages for these categories should only include
prepared foods that are consumed on the premises or sold for
carryout (i.e., foods not intended for home preparation or
consumption).

Questions 13 and 14 - Ownership Questions:
For each question, check only one box.

Question 13b, 13d or 14a: If you answer "Yes" to either
question 13a, 13c or 14, provide an explanation.

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 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/retailer/training.

Question 13g: If you answer "No" to question 13f, provide an
explanation.
Question 13i: If you answer "Yes" to question 13h, provide an
explanation.
Question 13k: If you answer "Yes" to question 13j, enter the
number of currently authorized SNAP stores under your
ownership.

Question 15 - EBT Provider Information: Enter the
Name, Phone Number and Address of the company that
provides your EBT equipment and services.

Question 16 - Financial Institution Name and
Address: Provide the name and address of the financial

institution that you use for SNAP payment deposits (i.e. what is
your bank?).

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Question 17 - Store Website: If you have a public
website for your store, please enter the full website address.
Question 18 - Additional Information or
Comments: Enter any additional information or comments

you would like to provide to FNS, such as Store name change,
updated mailing address, new or updated email address for
each owner or officer listed in question 12, or any special
circumstances that FNS should know.

Name and Signature - Before you sign Form FNS-252-R,
read the attached Privacy Act Statement, Use and Disclosure
Statement, Penalty Warning Statement, and Certification and
Signature Acknowledgment.
Print your full name and business title. Sign and date in the
space provided. Provide a phone number where we can call you
if we have questions about the information you provided. Mail
the form in accordance with Where to Mail Form FNS-252-R
section in the General Instructions.

Privacy Act and Paperwork Reduction Notice
Public reporting burden for this collection of information is
estimated to vary from 1 to 90 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, 1320 Braddock
Place, 5th floor, Alexandria, VA 22314. Attn: PRA. Do not
return the completed form to this address. Instead, see Where to
Mail Form FNS-252-R section of these instructions.
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.

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