Part 4 - Ownership Information
Not Applicable
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.
Form of Ownership:
Sole Proprietorship
Partnership
Privately-held corporation
Limited Liability Company
Publicly-owned Corporation (if you check this, skip to Part 6)
Enter primary owner(s) or corporate officer(s) if one or if more people or a private for-profit corporation owns the meal service. In
community property states, the spouse's information must also be entered. Community property states are: Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Texas, the state of Washington, and Wisconsin. Print names as they appear on the social security card.
Name (First, Middle, Last):
Title:
Date of Birth:
Social Security Number:
E-mail (optional):
Home Address:
City:
State:
Zip:
Enter other owner's or officers; information below, if applicable.
Name (First, Middle, Last):
Title:
Date of Birth:
Social Security Number:
E-mail (optional):
Home Address:
City:
State:
Zip:
Name (First, Middle, Last):
Title:
Date of Birth:
Social Security Number:
E-mail (optional):
Home Address:
City:
State:
Zip:
Part 5 - Business Information
Is any officer, owner, partner, or member currently or ever been suspended or debarred from conducting
Yes
No
business with or participating in programs administered by the Federal Government?
If Yes, please explain:
Is any officer, owner, partner, or member currently receiving SNAP benefits?
Yes
No
Yes
No
If Yes, and the meal service is already operating under your ownership, have you reported the income from
the meal service to your SNAP case worker?
If No, please explain below:
Has any officer, owner, partner and/or member ever been disqualified from receiving SNAP benefits as a
Yes
No
recipient for an intentional program violation (IPV) or fraud?
If Yes, please explain:
Yes
No
Does any officer, owner, partner, or member currently own any other SNAP authorized stores or meal services?
If Yes, how many currently authorized stores or meal services do you own?
Has any officer, owner, partner, or member ever been denied, withdrawn or suspended, or been fined for
Yes
No
license violations (such as the Supplemental Nutrition Assistance Program, business, alcohol, tobacco, lottery,
or health licenses)? If yes, provide an explanation on a separate sheet of paper.
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