Form Fns-252-2 - Usda Supplemental Nutrition Assistance Program Application For Meal Services Page 4
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7Has any individual involved in the ownership or management of the meal service ever been convicted of any
Yes
No
crime? If yes, provide an explanation on a separate sheet of paper.
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.
Part 6 - Agreement and Signature Block
I understand and agree:
• 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provide false information, my application may be denied or withdrawn.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:
– 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• Participation can be denied or withdrawn if the meal service violates any laws or regulations issued by Federal, State or local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.
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).
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.
X
X
Signature
Print Name
Date Signed
Print Title
Submit the supporting documentation as requested in Attachment A.
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