9080-4 Meat, Poultry, and Egg Product List

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0583-XXXX. The time required to complete this information collection is estimated to average10 minutes 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.
U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

MEAT, POULTRY AND EGG PRODUCT LIST
1. Establishment Name and Number *

2. EV*
Yes

No

3. Product Information
a. Producing Code *
b. Product as Labeled *
c. Date Effective

Through

d. First Species *
e. Second Species
f. Third Species
g. Finished Product Category
h. GPC Product Cut
i. GPC Boneless Claim
j. GPS Level of Cooking
k. GPC Mechanical Processing
l. GPC Meat Form
m. GPC Meat Shape
n. GPC Non-Thermal Preservation
o. GPC Primary Additive
p. GPC Refrigeration State
q. Anatomical Component
r. Maturity
s. Country of Slaughter
t. Country of Origin
u. Foreign Processing Country
v. Product Weight
w. Product Weight UOM
x. Package Count UOM
A knowingly false entry or false alteration of any entry on this certificate may result in a fine of not more than $10,000 or imprisonment of not more than five
years or both (18 USC 1001). Additionally penalties exist under the Federal Meat Inspection Act [21 USC 611 (b) (1), (2), and (5). 21 USC 676] and the Poultry
Products Inspection Act [21 USC 458 (c) (1), (2), and (5), 21 USC 461] and the Egg Products Inspection Act [21 USC 1037 (e) (2), (3), and (6). 21 USC 1041] for
an unauthorized or false alteration or misuse of this certification.
* Required
FSIS FORM 9080-4 (3/2/2010)