State and Local Government

Retailer List

OMB Number: 0584-NEW Expiration Date: MM/DD/20YY

INSTRUCTIONS: Please provide a list of all retailers and their stores or other outlets (such as farmers' markets or mobile vending vehicles) participating in eHIP in the state, along with their FNS store IDs, locations, store type, eHIP implementation method, and whether they currently participate in another incentive program. For retailers with multiple locations, please enter one location per line. Additional detail, including implementation method if select "Other," can be provided in the Notes column. Add stores to the list when they start accepting eHIP. Once added, a store's information need not be updated unless there are known changes in other incentives offered.

State:

Washington

Year:

2025

Month:

June

[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: Should we specify store name e.g., Feed Bags #111? Reply: Option - note in instructions Retailer or Store name

[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: Instructions: Prefer FNS ID; will accept merchant's internal ID as long as it matches the retailer-level incentives report. FNS Store ID (to match next tab)

Store type

Address (number and street, city, zip code)

eHIP Start Date

Implementation Method

Currently offering GusNIP nutrition incentive?

Currently offering GusNIP produce prescription?

Currently offering Healthy Fluid Milk Incentive?

Currently offering other (non-Federal) nutrition incentive? (if yes, specify in Notes)

Notes

[example: Feed Bags]

123456

CS--Convenience Store

123 Main St., Anytown, 12345

12/1/2024

Stand-beside POS/manual

Yes

Yes

Don't know

No

*

*

This information is being collected to provide the Food and Nutrition Service (FNS) with key cost information on Electronic Healthy Incentives Projects conducted by SNAP State agencies. This is a voluntary collection, and FNS will use the information to examine costs of Electronic Healthy Incentives Projects for SNAP. This collection requests personally identifiable information under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-NEW. The time required to complete this information collection is estimated to average 7 hours (420 minutes) per response. 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 (0584-NEW). Do not return the completed form to this address. If you have any questions, please contact the FNS Project Officer for this project, Kathleen Patton, at [email protected] or 703-305-2813.