Form 9010-1 Application for the Return of Exported Products to the U

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 0583-0159. The time required to complete this information collection is estimated to average 20 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.

2. EXPORT CERTIFICATE NO. (Attach Copy)
(i.e. MPM-000000 or US-CA-yyyy-000000)

U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

APPLICATION FOR THE RETURN OF EXPORTED PRODUCTS TO THE UNITED STATES
1. DISTRIBITION:

Applicant must submit the completed form to USDA, FSIS.
See Page 2 for address and instructions.

3. APPLICANT (Name and Address including zip code, contact name, phone number and email)

4. US PORT OF ENTRY

5. ESTIMATED DATE OF ENTRY (mm/dd/yyyy)

6. EXPORT. EST. NO.

7. U.S. EXPORT EST. NAME AND ADDRESS

9.
PRODUCT AS LABELED

15. PORTS TRANSITED

10.
MARKED
WEIGHT

11.
NO. OF
CARTONS

16. COUNTRY RETURNED FROM

8. DATE OF REQUEST (mm/dd/yyyy)

12.
PRODUCTION CODE

14.
EST. NO.
ON PRODUCT

13.
SHIPPING MARKS

(Applied at Time of Export)

17. REASON FOR RETURN

19. DATE AT EST. (mm/dd/yyyy)

18. REINSPECTION OFFICIAL FSIS ESTABLISHMENT*

*Applicants should identify an official FSIS establishment for reinspection, if required, and a date for the reinspection. Approval of the establishment and reinspection date
depends on concurrence from the District Office of Field Operations.
20. COMMENTS/REMARKS

TO BE COMPLETED BY FSIS PERSONNEL ONLY
21. REINSPECTION REQUIRED
(date and initials)

25. SIGNATURE OF STAFF OFFICER

FSIS FORM 9010-1 (05/13/2019)

22. APPLICATION DENIED
(date and initials)

23. APPLICATION CANCELLED
(date and initials)

24. RELEASED
(date and initials)

26. DATE (mm/dd/yyyy)

Submit via E-mail

INSTRUCTIONS FOR PREPARATION OF FSIS FORM 9010-1
Note:
1.

The information on the form can be typed or written to be completed by Applicant
Submit Form: Click the "Submit via E-mail" button at the bottom of the form or the form may be printed and scanned
or saved as a .pdf and emailed to: [email protected]
For assistance, please call (202) 720-9904

2.

Export Certificate Number - As identified on certificate and shipping cartons

3.

Applicant - Information regarding applicant's company, including the company's address, phone number, and email address. Include
the name of person filling out application (the applicant's representative)

4.

U S Port of Entry - City and State of U S Port of Entry either entering sea or ground/air

5.

Estimated Date of Entry - Estimated Date when the product is to arrive in the US (Month, Day, and Year)

6.

Originating Export Establishment - Establishment number where export originated from

7.

U S Establishment - Export Establishment Name and Address - Full address (street, city, state and zip code ) where export originated
from

8.

Date of request - Date application is completed and submitted

9.

Product as labeled - Species, Total Ship Weight and Product as described on Label or Export documents, e.g. "Beef Boneless Rounds"

10.

Marked Weight - Total Shipment Weight in pounds

11.

No. of Cartons - The numeric count of product returning

12.

Production Code - Date produced or other production codes. Information in this field is not required if that information is unavailable.

13.

Shipping Marks (Applied at Time of Export) - Export Stamp number

14.

Establishment No. on Product - Producing establishment number of the returned product

15.

Ports Transited - All ports visited by the shipment - leaving and returning to the U.S.

16.

Country Returned from - Country product was exported to as listed on export certificate

17.

Reason for Return - Reason product is returning the US (e.g. Refused for contamination, Returned because not up to
specifications, etc.)

18.

Reinspection: Official FSIS Establishment - The FSIS Establishment proposed for reinspection, should it be required,
pending concurrence from the appropriate District

19.

Date - Estimated date the shipment will arrive for reinspection (at the establishment listed in block 18)

20.

Comments/Remarks - Comments by the applicant and/or FSIS personnel

BLOCKS 21 through 26 FOR FSIS PERSONNEL USE ONLY
21.

Reinspection Required - Date and initials of the FSIS staff officer if shipment must be reinspected at location specified in
block 18.

22.

Application Denied - Date and initials of the FSIS staff officer if the shipment is denied entry in the US.

23.

Application Cancelled - Date and initials of the FSIS staff officer if the shipment has been cancelled by the applicant.

24.

Released - Date approved to move if reinspection is not required or acceptable results are reported by DO after
reinspection.

25.

Signature of Staff Officer - signature of FSIS staff officer completing the return.

26.

Date - date final action is taken by the FSIS staff officer.