8570-27 Formulator's Exemption

Form Approved. OMB No. 2070-0060.
United States

Environmental Protection Agency
Washington, DC 20460

Formulator’s Exemption Statement
(40 CFR 152.85)
Applicant’s Name and Address

EPA File Symbol/Registration Number

Product Name

Date of Confidential Statement of Formula (EPA Form 8570-4)

As an autho rized repres enta tive of the ap plican t for registration of the produ ct iden tified above, I certify that:
(1) This product con tains the following active ingredient(s):

(2) Of these, each a ctive ingredient listed in paragraph (4) is present solely as the result of the use of that active
ingre dient in the m anu facturing, form ulation or rep ack aging an othe r produc t which co ntains that ac tive ingre dient
which is re gistered u nde r FIF RA Sec tion 3, is p urchas ed b y us fro m ano ther p rodu cer, and is labeled for at leas t
each use for which my product is proposed to be labeled.
(3) Indicate by checking (A) or (B) below which paragraph applies:

G (A) An accurate Confidential Statement of Formula (EPA FORM 8570-4) for the above identified product is
attache d to this statem ent. T hat fo rm ula sta tem ent ind icates , by com pan y nam e, reg istration num ber, a nd p rodu ct
name , the source of the active ingredient(s) listed in paragraph (1).
OR

G (B)T he Co nfidentia l Sta tem ent of Fo rm ula (CSF )(E PA Fo rm 8570-4) referenced above and on file w ith th e EPA is
complete, current, and accurate and contains the information required on the current CSF.
(4) The following active ingredients in this product qualify for the formulator’s exemption.
Source
Active Ingredient

Signature
EPA Form 8570-27 (Rev. 12-2003)

Product Name

Nam e and Title

Registration Number

Da te
Copy 1 - EPA
Copy 2 - Applicant copy

Paperwork Reduction Act Notice
The public reporting burden for this collection of information is estimated to average 1.5. hours
per response, including familiarization with the form, organizing the necessary information, and
completing the form. Send any comments regarding the burden estimate or any other aspect of this
collection of information to: Director, Collection Strategies Division (2822T), U.S. Environmental
Protection Agency, 1200 Pennsylvania Avenue, N.W., Washington, DC 20460. Do not send the
completed form to this address.

EPA Form 8570-27 (Rev. 12-2003) Reverse

Copy 1 - EPA
Copy 2 - Applicant copy