EBT Retailer Application - How to Get EBT At Your Store

Apply for EBT for Your Buiness

Please complete the information below to start your EBT license application process. Once you submit this information, an attorney from Metropolitan Law Group will review your application to make certain that no issues will arise, and then contact you for verification. Please be aware that an attorney-client relationship is not created simply by submitting information on this form, nor will your application be submitted by Metropolitan Law Group until you give us permission to do so.

When did or when will the store open for business under your ownership?*
Date Format: MM slash DD slash YYYY
Store Name:*
Doing Business As (If Different from Store Name):
Chain Store Number (if applicable):
Store LOCATION Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Store MAILING Address:*
Same as Location Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Store Telephone Number*
Alternate Phone Number
Is your business a delivery route, food buying cooperative, farmers' market, farm stand/stall/u-pick, military commissary/exchange or specialty food store that primarily sells one food type such as meat/poultry, seafood, bread, or fruits/vegetables?*
- Yes
- No
Which of the following does your store qualify as?*
- Meat/Poultry Market
- Bakery
- Military Commissary/Exchange
- Farmer's Market
- Food Buying Cooperative
- Seafood Market
- Produce Market
- Delivery Route
- Direct Marketing Farmer (Farm Stand/Stall/U-Pick)
Type of Ownership (must select only one):*
- Privately Held Corporation
- Sole Proprietorship
- Limited Liability Company
- Nonprofit Organization
- Publicly Owned Corporation
- Partnership
- Government Owned
Is your company legally organized as a nonprofit entity?*
If yes, does your firm have 501(c)(3) nonprofit tax-exempt status?*
Corporation or Government Agency Information
If your firm is a privately held corporation, nonprofit organization, or limited liability company, enter the name and address of your corporation as on record with the State. If government owned, enter the name and address of the responsible government agency. If publicly owned corporation, enter the name and address of the parent corporate office. All others skip to the next question.
Same as Location Address
Street Address Address Line 2 City State ZIP Code
If your company is publicly or government owned, enter a contact person:
If you have an Employer Identification Number (EIN) enter it here:
Owner/Officer Information*
Enter the name and home address of all officers, owners, partners, and members. You must enter spousal information for each owner and officer if your business is located in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI). If this is a publicly owned corporation or government owned store, skip to question 15. Please write the name of the individual as it appears on his/her social security card.
First Middle Last
First Owner/Officer/Partner/Member Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Second Owner/Officer/Partner/Member Name
First Middle Last
Second Owner/Officer/Partner/Member Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Third Owner/Officer/Partner/Member Name
First Middle Last
Third Owner/Officer/Partner/Member Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Fourth Owner/Officer/Partner/Member Name
First Middle Last
Fourth Owner/Officer/Partner/Member Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Ownership Information
Please answer the following questions as they apply to all owners, officers, partners, Members, and or Managers. Provide information where appropriate.
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, please provide an explanation:
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?*
If Yes, please provide an explanation:
Is any officer, owner, partner, and/or member currently receiving assistance through the Supplemental Nutrition Assistance Program (SNAP)?*
If Yes, has the officer, owner, partner, and/or member reported this store ownership to their SNAP caseworker?*
If No, please provide an explanation:
Has any owner, officer, partner and/or member ever been disqualified from receiving assitance through the Supplemental Nutrition Assistance Program for an intentional program violation (IPV) or fraud?*
If Yes, please provide an explanation:
Does any officer, owner, partner, and/or member currently own any other SNAP authorized stores?*
If Yes, how many currently authorized stores does the owner, officer, partner and/or member currently own?*
Was any officer, owner, partner, member, and/or manager convicted of any crime after June 1, 1999?*
If Yes, please provide an explanation.*
Business Information
This section asks about your store's sales, revenue, inventory and other business practices.
Do you sell products wholesale to other businesses such as hospitals or restaurants?*
If Yes, do your retail food sales meet or exceed $250,000 or 50% of your total gross sales?*
Do you have, or are you applying for a restaurant license for your store?*
Indicate the number of <ul>varieties</ul> in the Breads and/or Cereals staple food category that your store carries. (Examples include: rice, pasta, flour, pita, tortilla, etc.) To qualify, these varieties must be offered currently and on a continuous basis in your store.*
Indicate the number of <ul>varieties</ul> in the Dairy staple food category that your store carries. (Examples include: soymilk, butter, yogurt, infant formula, etc.) To qualify, these varieties must be offered currently and on a continuous basis in your store.*
Indicate the number of <ul>varieties</ul> in the Meat, Poultry and/or Fish staple food category that your store carries. (Examples include: beef, pork, eggs, tuna, chicken, etc.) To qualify, these varieties must be offered currently and on a continuous basis in your store.*
Indicate the number of <ul>varieties</ul> in the Vegetables and/or Fruits staple food category that your store carries. (Examples include: apples, tomatoes, peaches, carrots, etc.) To qualify, these varieties must be offered currently and on a continuous basis in your store.*
Do you have at least three stocking units of EACH variety in the Breads and/or Cereals category? (For example, 3 bags of rice, 3 boxes of pasta, etc.)*
Do you have at least three stocking units of EACH variety in the Dairy products category? (For example, 3 gallon containers of milk, 3 containers of yogurt, etc.)*
Do you have at least three stocking units of EACH variety in the Meats, Poultry and Fish category? (For example, 3 cans of tuna, 3 bags of frozen chicken, etc.)*
Do you have at least three stocking units of EACH variety in the Fruits and Vegetables category? (For example, 3 apples, 3 bags of potatoes, etc.)*
Do you have at least one variety of PERISHABLE foods in the Breads and/or Cereals category (Examples: bread, pita, etc.)?*
Do you have at least one variety of PERISHABLE foods in the Dairy products category (Examples: refrigerated milk, refrigerated butter, etc.)?*
Do you have at least one variety of PERISHABLE foods in the Meat, Poultry and Fish category (Examples: fresh eggs, frozen chicken, etc.)?*
Do you have at least one variety of PERISHABLE foods in the Fruits and Vegetables category (Examples: fresh apples, frozen broccoli, etc.)?*
Business Revenue Records
This section asks for your revenue records from the one year period immediately preceding your application. If you do not sell a particular category of products, please place a "0" in the box. Also, please select "Actual Sales" or "Estimated Sales." If you use "Actual Sales" please use the figures from your most recent IRS tax year,
Are these Estimated Sales or Actual Sales?*
- Estimated
- Actual
Tax Year for Actual Sales*
What Tax Year Are the Actual Sales From?*
Gasoline Revenue*
Please enter a number greater than or equal to 0.
Lottery Revenue*
Please enter a number greater than or equal to 0.
Tobacco Revenue (Cigarettes, cigars, chewing tobacco, etc.)*
Please enter a number greater than or equal to 0.
Alcohol Revenue (Beer, wine, etc.)*
Please enter a number greater than or equal to 0.
Non-Food Revenue (Paper products, car care, pet food, soap, etc.)*
Please enter a number greater than or equal to 0.
Hot-Food Revenue (Hot coffee, hot soup, hot pizza, etc.)*
Please enter a number greater than or equal to 0.
Cold-Prepared Food Revenue (Made to order sandwiches, salads, etc.)*
Please enter a number greater than or equal to 0.
Accessory Food Revenue (Ice cream, potato chips, soda pop, doughnuts, etc.)*
Please enter a number greater than or equal to 0.
Staple Food Revenue (Breads and Cereals, Meats, Poultry and Fish, Dairy, Fruits and Vegetables, etc.)*
Please enter a number greater than or equal to 0.
Total Sales
How many cash registers are at this store?*
Please enter a number greater than or equal to 0.
Are optical scanners used at this store?*
Is this store open year round?*
If No, check what months you are open:*
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
Is your store open 7 days a week, 24 hours per day?*
If No, please type what days and hours you are open below:*
Please provide the name and address of the financial institution (bank) that you will be using for SNAP payment deposits:
Financial Institution Name
Financial Institution Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If known, please provide the name, phone number, and mailing address of the Electronic Benefits Transfer (EBT) equipment provider for your store:
EBT Equipment Provider Name
EBT Equipment Provider Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have a website for your store?
Do you have any additional information or comments you would like to provide to FNS (such as any special circumstances FNS should know)? If so, please write it below.
By submitting this information, you acknowledge that this submission is for information purposes only, and does not create an attorney-client relationship with Metropolitan Law Group, PLLC (the "Firm"). I give the Firm permission to contact me regarding the application information set out above, and acknowledge that the Firm will not submit my application until I have reviewed and approved a final application after the Firm is retained.*
I agree.
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Apply for EBT for Your Buiness

Ownership Information

Business Information

Business Revenue Records