Ingredient Report

Form Approved

OMB No. 0920-0210

Exp. 02/28/2014

Recommended Ingredient Reporting Format - CSTHEA

Please attach additional pages if necessary

Date

Office on Smoking and Health

Attn. FCLAA Program Manager

4770 Buford Hwy., NE, MS K-50

Atlanta, GA 30341

This ingredient report is being submitted pursuant to the Federal Cigarette Labeling and Advertising Act (FCLAA), 15 U. S.C. §1335 (a) Public Law 89–92.

Company Name(s)*

Brand(s)†

*If this Ingredient Report is submitted by a designated individual or entity on behalf of a cigarette manufacturer, packager, or importer, the form must specify on whose behalf the submission is being made.

†Inclusion of the brand name and product type for ingredients is not required under CSTHEA.

Public reporting burden of this collection of information is estimated to average 6.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0210).

Ingredient Name ¶ CAS Registry Number§

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