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U.S. Department of Health and Human Services

Food

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Small Business Nutrition Labeling Exemption Notice Model Form

FDA Form 3570 (1/11)
OMB Approval Number: 0910-0381
OMB Expiration Date: 12/31/2013
See OMB Burden Statement

Small Business Nutrition Labeling Exemption

Appendix I -- Model Small Business Nutrition Labeling Exemption Notice
FDA Form 3570 (1/11)

PLEASE TYPE OR CLEARLY PRINT IN BLANK SPACES
1.
Name of Firm
_______________________________________________________________________
 2.
Street Address of Firm
_______________________________________________________________________
 
City
___________________________________ State____________ Zip/Postal code__________
 
Country
_________________________________________
 
Telephone
_________________________________ Fax ___________________________________
 
E-mail
_______________________________________________________________________
3.
Type of Firm (Check all that apply)
 
Manufacturer __________________ Packer/Repacker __________________ Retailer __________________
 
Distributor __________________ Importer __________________
4. Twelve-month time period for which you are claiming exemption – Provide the applicable time period for the CURRENT YEAR__________
Example: 5/8/2005-5/7/2006 (Month/day/year-Month/day/year)
 
5.Average number of full-time equivalent employees for 12 month period ___________________
Include the owner of the firm as one employee. Do not list "0" employees.
6.Report of units sold (Use continuation sheet if necessary) If new business, estimate number of units to be sold in upcoming year.
Name of Product
No. of Units
Manufacturer (A)
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
7.Name and address of Manufacturer(s), Distributor(s), or Importer(s) of Product(s) in Item 6 if Different from Firm Claiming an Exemption. (Use continuation sheet if necessary.)
_B_
Name of Manufacturer, Distributor, or Importer
__________________________________________________
 
Address
__________________________________________________
_C_
Name of Manufacturer, Distributor, or Importer
__________________________________________________
 
Address
__________________________________________________
8.Contact Person _______________________________________________________ Telephone Number ____________________
9.The undersigned certifies that the above information is complete and accurate. The undersigned will notify the Office of Nutritional Products, Labeling and Dietary Supplements of the date on which the average number of full-time equivalent employees or the number of units of products sold in the United States by my firm exceeds the applicable numbers for the time period for which the exemption is being claimed.
Signature ____________________________________________________________________________
Name (Type or clearly print) ______________________________________________________________
Title ________________________________________________________________________________
Date ________________________________________________________________________________