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Food

Small
Business Nutrition Labeling Exemption

Small
Business Nutrition Labeling Exemption Notice Model Form

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Small Business Nutrition Labeling Exemption Notice Model
Form

FDA Form 3570 (2/07)
OMB Approval Number:
0910-0381
OMB Expiration Date: 8/31/2010
See
OMB Burden Statement

Small Business Nutrition Labeling Exemption

Appendix I --
Model Small Business Nutrition Labeling Exemption Notice
FDA Form 3570
(2/07)

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 ________________________________________________________________________________

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