Fillable USDA Supplemental Nutrition Assistance Program (Arizona)

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USDA Supplemental Nutrition Assistance Program (Arizona)

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You need to complete a separate FNS-252-2 application for each type of meal service you operate.
FORM FNS-252-2 (04-19) Previous Editions Obsolete
USDA Supplemental Nutrition Assistance Program
Application for Meal Services
Private For-Profit Restaurant
Page 1 of 7
FOR USDA USE ONLY
FNS Number:
Date Authorized:
Authorization Initials:
Sponsor Type:
County Code:
Part 1 - Meal Service Types
Directions: Review the descriptions below and check the meal service type that describes the meal service.
You may only check one box (one meal service type) per application.
Private For-Profit Restaurant means private for-profit establishments that contract with an
appropriate State or local agency to offer meals at concessional prices to homeless,
disabled, and/or elderly persons and their spouses or supplemental security income (SSI)
recipients and their spouses.
Drug and/or Alcohol Treatment Program means any drug addiction or alcoholic
treatment and rehabilitation program conducted by a private nonprofit organization or
institution, or a publicly operated community mental health center, that is operating under
part B of Title XIX of the Public Health Service Act (42 U.S.C. 300x et. seq.).
Meal Delivery Service or Private For-Profit Meal Delivery Service means a public or a
private organization that prepares and delivers meals to elderly persons and their spouses
and/or to the physically or mentally handicapped and persons otherwise disabled, and their
spouses if they are unable to adequately prepare all of their meals.
Communal Dining Facility means a public or private nonprofit establishment that prepares
and serves meals for elderly persons and their spouses or for SSI recipients and their
spouses.
Homeless Meal Provider means a public or private nonprofit establishment (e.g., soup
kitchen, temporary shelter), approved by an appropriate State or local agency, that feeds
homeless persons. If the site receives donated food items from USDA, the site must also
purchase and serve other food.
Shelter for Battered Women and Children means a public or private nonprofit residential
facility that serves meals or provides food to battered women and children. If such a facility
serves other individuals, part of the facility must be set aside on a long-term basis to serve
battered women and children.
Group Living Arrangement means a public or private nonprofit residential setting that
serves no more than 16 residents and that is certified by the appropriate State agency or
agencies in accordance with 1616(e) of the Social Security Act or meets comparable
standards as determined by USDA.
Private For-Profit Senior Citizens' Center or Residential Building means a facility that
prepares and serves meals to elderly, disabled, or SSI recipients. Participating residential
buildings must be occupied primarily by elderly or SSI recipients and serves meals to such
persons, and does not provide a majority of the residents' meals (over 50 percent of three
meals daily) as part of the institution's normal services.
Franchise NoYes
Private Nonprofit
Organization/Institution
Publicly Operated
Organization/Institution
Public Meal Delivery
Private Nonprofit Meal Delivery
Private Nonprofit
Communal Facility
Public Communal Facility
Private Nonprofit
Establishment
Public Establishment
Private Nonprofit Facility
Public Facility
Public Facility
Private Nonprofit Facility
Senior Citizens Center
Residential Building
Private For-Profit Meal Delivery
Electronic Form Version Designed in Adobe 10.0 Version
SBU
OMB APPROVED NO. 0584-0008
Expiration Date: 01/31/2021
List additional sites on a separate sheet of paper and attach, using the same format above.
City:
Zip:State:City:
Location Address:
Enter Site Location address if it is different from the
Location Address entered above in Part 2.
Site Name #1:
Page 2 of 7
( ) –
If a Group Living Arrangement, number of residents served:Telephone:
Title:Person Responsible for On-Site Operation, if different from Part 2:
State: Zip:
Check days of operation: M T W TH F SA SU Meals served: Breakfast Lunch Dinner
Person Responsible for On-Site Operation, if different from Part 2: Title:
Telephone: If a Group Living Arrangement, number of residents served:
Federal Employer Identification Number (EIN), if applicable: Name of Person Responsible for Operation of Meal Service:
Mailing Address:
Legal Business Name (if different from Sponsoring Organization or Business Name):
Name:
Part 2 - Sponsoring Organization or Business
Directions: All applicants must complete this section.
Zip:State:City:
Location Address:
Title: Telephone: Fax, optional:
E-mail (required):
Number of sites to accept Supplemental Nutrition Assistance Program benefits:
Part 3 - Site Specific Information - Site Where Meals Are Served
Directions: All applicants must complete this section. You must provide information on all meal sites under the meal service's sponsorship,
including all locations from which deliveries originate or sites where benefits are accepted.
City: State: Zip:
Site Name #2:
Check days of operation: M T W TH F SA SU Meals served: Breakfast Lunch Dinner
Location Address:
Person Responsible for On-Site Operation, if different from Part 2: Title:
Telephone: If a Group Living Arrangement, number of residents served:
–)(
City: State: Zip:
Site Name #3:
Location Address:
DinnerLunchBreakfastMeals served:SUSAFTHWTMCheck days of operation:
( ) ––)(
–)(
Home Address:
City:
State: Zip:
Home Address:
Date of Birth: Social Security Number: E-mail (optional):
Zip:State:City:
Name (First, Middle, Last): Title:
E-mail (optional):Social Security Number:Date of Birth:
Title:Name (First, Middle, Last):
Home Address:
Part 4 - Ownership Information
Directions: Complete this section only if you are a private for-profit restaurant, private for-profit meal delivery service, or
private for-profit senior citizens center or residential building. Applicants with 501(c)(3) non-profit tax-exempt status skip to
Part 5.
Part 5 - Business Information. Must be completed by all applicants.
Page 3 of 7
Enter primary owner(s) or corporate officer(s) if one or if more people or a private for-profit corporation owns the meal service. Print
names as they appear on the social security card.
Form of Ownership:
Limited Liability CompanySole Proprietorship Partnership Privately-held corporation
Publicly-owned Corporation (if you check this, skip to Part 6)
Name (First, Middle, Last): Title:
Date of Birth: Social Security Number: E-mail (optional):
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?
Does any officer, owner, partner, or member currently own any other SNAP authorized stores or meal services?
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?
Is any officer, owner, partner, and/or member currently receiving assistance through the Supplemental Nutrition
Assistance Program?
If Yes, has the officer, owner, partner, and/or member reported this meal service ownership to their SNAP
caseworker?
If Yes, please explain:
If No, please explain below:
If Yes, how many currently authorized stores or meal services do you own?
Yes
If Yes, please explain:
Yes
No
Yes No
Yes
No
NoYes
No
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? If yes, provide an explanation on a separate sheet of paper.
No
Yes
Zip:State:City:
Submit the supporting documentation as requested in Attachment A.
I understand and agree:
Part 6 - Agreement and Signature Block
• I have the authority to contract for the meal service.
• I have provided truthful and complete information on this form.
• I hereby agree to release to the Department of Agriculture (USDA), by my signature below my tax records and also to allow
USDA to verify the accuracy of information submitted with this application.
• Any information I have provided or will provide may be verified and shared by the USDA as described in attachment B. If I
provide false information, my application may be denied or withdrawn.
• I accept responsibility to report changes in the meal service's ownership, address, type of business, and operation to FNS.
• I will follow, and ensure representatives will follow, the Supplemental Nutrition Assistance Program regulations.
• I am aware that violations of program rules can result in fines, legal sanctions, withdrawal, or disqualification from the
Supplemental Nutrition Assistance Program.
• I accept responsibility on behalf of the meal service for violations of the Supplemental Nutrition Assistance Program regulations,
including those committed by any of the meal service's representatives, both paid or unpaid, new, full-time or part-time. These
include violations, such as but not limited to:
Page 4 of 7
– Trading cash for Supplemental Nutrition Assistance Program benefits;
– Knowingly accepting Supplemental Nutrition Assistance Program benefits from people not authorized to use them;
– Accepting Supplemental Nutrition Assistance Program benefits as payments on credit accounts or loans;
– Using Supplemental Nutrition Assistance Program benefits to cover the cost of room and board or treating
Supplemental Nutrition Assistance Program customers differently than other customers;
– Accepting Supplemental Nutrition Assistance Program benefits as payments for ineligible items.
• Participation can be denied or withdrawn if the meal service violates any laws or regulations issued by Federal, State or local
agencies, including civil rights laws and their implementing regulations.
• Participation in the Supplemental Nutrition Assistance Program requires that I will not discriminate against any customer on the
grounds of race, color, national origin, age, sex, handicap (disability), political belief or religion; and that I will immediately take any
measures necessary to make sure that my customers are not discriminated against.
• Any individual or meal service accepting or redeeming Supplemental Nutrition Assistance Program benefits, if not authorized to
do so, is subject to substantial fines and administrative sanctions.
• Approval to participate will be automatically withdrawn and the meal service will no longer be able to accept Supplemental
Nutrition Assistance Program benefits upon loss of Federal tax-exempt status, cancellation or expiration of its contract with the
State or local agency, or loss of its State certification, if required as a condition of eligibility.
• 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. If your store is permanently disqualified, all owners' names will be publicly disclosed through
the General Service Administration's (GSA) System for Award Management (SAM). Being listed in GSA-SAM could affect your
ability to get or keep a job or to receive a private loan for your business or for a house, car, or college.
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.
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).
Provide the name and address of the financial institution (bank) that you will be using for SNAP payment deposits.
Signature
Date Signed
X
Print Name
Print Title
X
Was any individual involved in the ownership or management of the meal service convicted of any crime after
June 1, 1999? If yes, provide an explanation on a separate sheet of paper.
No
Yes
If you have additional information or comments you would like to provide to FNS (such as a contact person to discuss the
application), please provide the information here.
Financial Institution Mailing Address:
Zip:State:City:
Financial Institution Name:
If foreign address, add Country:
Additional Address (Bldg #, Unit #, Stall #, etc.):
Page 5 of 7
Directions: Provide all of the required documentation for the meal service type for which you are applying, along with the completed
application form. Please keep attachments A and B for your records.
ATTACHMENT A - MEAL SERVICE APPLICATION REQUIRED DOCUMENTATION LIST
Required Documentation: (Provide all of the following)
SECTION A: Private For-Profit Restaurant or For-Profit Meal Delivery Service
SECTION B: Alcohol and/or Drug Treatment Program
• Copy of a government issued photo identification card and a copy of a Social Security card, or other verification of Social Security
Number, for:
all owners/partners
all officer(s) of private corporations
NOTE: Above documentation is not required for publicly-owned corporations
• Copy of the contract with the State agency
• Copy of a valid business license
• Signed certification and signature statement (page 4 of the application) for each owner, partner, and corporate officer.
Required Documentation:
Required Documentation: For the four meal service types listed above, provide proof of the meal service's 501(c)(3) non-profit tax-
exempt status as recognized by the Internal Revenue Service, and a signed certification and signature statement (page 4 of the
application) for each principal administrator, executive director, and responsible official.
SECTION C: Public or Private Non-Profit Meal Delivery Service; Public or Private Non-Profit Communal Dining
Facility; Public or Private Non-Profit Homeless Meal Provider; Shelter for Battered Women and Children
• Proof of 501(c)(3) non-profit tax-exempt status as recognized by the Internal Revenue Service
• Certification by the appropriate State agency in accordance with regulations issued under 1616(e) of the Social Security Act or
under comparable standards, as determined by the U.S. Department of Agriculture
• Signed certification and signature statement (page 4 of the application) for each principal administrator, executive director, and
responsible official.
• Proof of 501(c)(3) non-profit tax-exempt status as recognized by the Internal Revenue Service
• Certified by the State agency responsible for the rehabilitation of drug addicts or alcoholics (the State Title XIX agency) as:
i. Receiving part B Title XIX funding; or
ii. Operating under part B Title XIX even if no funds are being received; or
iii. Operating to further the purposes of part B of Title XIX, to provide treatment and rehabilitation of drug addicts and/or
alcoholics
• Signed certification and signature statement (page 4 of the application) for each principal administrator, executive director, and
responsible official.
Required Documentation:
SECTION D: Group Living Arrangement
• If applying as a Residential Building, a signed statement from the owner(s) certifying: (1) that the building is occupied primarily by
elderly persons (60 years of age or older) and SSI recipients and that it prepares and serves meals to such persons, and (2) that
it does not provide a majority of the residents' meals (over 50 percent of three meals daily) as part of the institution's normal
services
• Signed certification and signature statement (page 4 of the application) for each owner.
Required Documentation:
SECTION E: Private For-Profit Senior Citizens' Center or Residential Building
ATTACHMENT B
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 applicationual agreements with us for designing, developing, and operating our
systems, and for verification and computer matching purposes;
Page 6 of 7
• 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 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 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/meal service providers, 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 to verify the information reported by applicants and
participating firms/meal service providers, 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. 55 2a(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/meal service provider 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/meal service, 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.
Page 7 of 7
ATTACHMENT B - continued
Certification and Signature - By signing your name on this application, you are telling us that: (1) you are the meal service principal
administrator, executive director, owner or that the meal service owner(s) have asked you to apply for them; (2) the information you
and/or the owner(s) gave us on this form, or papers we asked for, is true, (3) you have read and understand all the information on this
sheet; (4) you understand that you and the person(s) for whom you are applying are responsible for stopping workers, paid or unpaid,
from breaking Supplemental Nutrition Assistance Program rules such as, but not limited to: (a) trading cash for Supplemental Nutrition
Assistance Program benefits; (b) taking Supplemental Nutrition Assistance Program benefits from people not allowed to use them; (c)
taking Supplemental Nutrition Assistance Program benefits to pay on a credit account or loan; (d) taking Supplemental Nutrition
Assistance Program benefits to pay for items not allowed to be paid for with Supplemental Nutrition Assistance Program benefits; (e)
treating Supplemental Nutrition Assistance Program customers differently than other customers. We can take away a meal service's
right to take Supplemental Nutrition Assistance Program benefits as payment of food provided at your meal service facility if any
owner(s), manager(s) or anyone working in the meal service violates any of the Supplemental Nutrition Assistance Program law or rules.
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.
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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USDA Supplemental Nutrition Assistance Program (Arizona)

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Completed 27 January 2021

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