Fillable FDA Product Data Sheet: Dietary Supplements (Livingston)

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FDA Product Data Sheet: Dietary Supplements (Livingston)

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FDA: Dietary Supplement 1 US Brokerage, 09/2015
FDA Product Data Sheet: Dietary Supplements
Account Number
Account Name
DUNS Number (if available)
Client Part Number*
Description of Product (as complete as possible)
Government Agency Processing Code
Tariff Number
FDA Product Code (if known)
Customs Country of Origin**
FDA Country of
Origin**
Cargo Storage Status
Processing (if other, specify)
Product is for
Please answer the following
Ready to Eat or Enrichment/additive for further manufacturing
Prescription/Rx or Non-Prescription
Single ingredient or Multiple ingredients
* Part number as shown on Customs document to identify the product (item number, SKU, etc.)
** U.S. Customs considers the country of origin to be the country where the product last underwent a “substantial transformation” (resulting in an
increase in value.) The FDA considers the country of origin to be that of the actual manufacturer. Actual manufacturer is defined as the last party
involved in the production of the food. 21 CFR 1.227(b)(2)
FDA Actual Manufacturer
Address
City
State/Province
Zip/Postal Code
Country
Food Facility Registration Number
DUNS Number (if available)
FDA Shipper (As shown on Customs document, BOL or airway bill)
Address
City
State/Province
Zip/Postal Code
Country
Food Facility Registration Number
DUNS Number (if available)
Prior Notice Submitter Information
Contact Phone No.
Contact E-mail Address
DSU Dietary Supplements
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FDA Product Data Sheet: Dietary Supplements (Livingston)

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Completed 23 September 2021

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