3570 Small Business Nutrition Labeling Exemption Notice

Form Approved: OMB No. 0910-0381. Expiration Date: mm/dd/yyyy. See PRA Statement on page 2.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
Center for Food Safety and Applied Nutrition

SMALL BUSINESS NUTRITION LABELING EXEMPTION NOTICE
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

Dietary Supplement

4. TWELVE-MONTH TIME PERIOD FOR WHICH YOU ARE CLAIMING EXEMPTION – Provide the applicable time period for the
CURRENT YEAR. Example: 05/08/2013-05/07/2014 (MM/DD/YYYY - MM/DD/YYYY)
5. AVERAGE NUMBER OF FULL-TIME EQUIVALENT EMPLOYEES FOR 12 MONTH PERIOD
Include the owner of the firm as an 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 OF PRODUCT (A)

Example: Chocolate Chip Cookies (multiple package sizes)

20,000

XYZ Baking Company

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

NAME OF MANUFACTURER, DISTRIBUTOR, OR IMPORTER
ADDRESS

FORM FDA 3570 (mm/yy)

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PSC Publishing Services (301) 443-6740

EF

SMALL BUSINESS NUTRITION LABELING EXEMPTION NOTICE (cont.)
8. CONTACT PERSON

TELEPHONE

9. The undersigned certifies that the above information is complete and accurate. The undersigned will notify the Office of
Nutrition, 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

TITLE

NAME (Type or clearly print)

DATE

Send your notice to:
Center for Food Safety and Applied Nutrition
Food and Drug Administration
HFS-820
5001 Campus Drive
College Park, MD 20740-3835

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FORM FDA 3570 (mm/yy)

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