SNAP Healthy Retailer Agreement Form

Welcome! This form is for all SNAP-authorized retailers in Virginia. Please use the form below to indicate your compliance with Virginia’s SNAP Food Restriction Waiver (“SNAP Healthy Beverage Update”) by November 1, 2026. If you have any questions, please contact SNAPHealthy@dss.virginia.gov.

Please Note: If you submit on behalf of multiple locations, please use the SNAP Healthy Multiple Locations Template  to upload a list of all locations. You will need contact information and addresses for each store. Contact information may be the same for all locations if applicable. 

By submitting the form below, I certify that: 

• I have reviewed and understand all applicable SNAP rules, including Virginia’s approved waiver.
• My business has taken the necessary steps to comply with these requirements prior to the effective date.
• I am authorized to sign on behalf of this retailer.
• I understand that failure to comply may result in penalties, including losing authorization to accept SNAP benefits.
• I agree to abide by all SNAP program rules, regulations, and guidance issued by the USDA Food and Nutrition Administration and the Virginia Department of Social Services.