9840-4 Voluntary Destruction of Imported Meat Poultry and Egg P

OMB Control Number: 0583-0182
Expiration Date: 06/30/2023

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 0583-0182. The time required to complete this information collection is
estimated to average 5 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.
Food Safety and
United
StatesDepartment InspectionService
of Agriculture

VOLUNTARY DESTRUCTION OF IMPORTED MEAT, POULTRY, AND EGG PRODUCT

As official representative(s)

I / we

elect to voluntarily destroy for human food purposes the following described product:
2. Customs Entry Number

1. Inspection Certificate Number
3. Country of Origin

6. Lot Number

7. Description
of Product

4. Processing Establishment Number

5. FSIS Establishment Number

8. Shipping Marks/
Identification

10. Quantity

9. Refused Entry
Date

11. Weight
(lbs.)

I/we understand that this product(s) was refused entry under the authority of the Federal Meat, Poultry, and Egg Products Inspection
Acts.
The disposal of the product(s) described above will be under the supervision of a representative(s) of the Food Safety and Inspection
Service, USDA, without recourse to the Government. This voluntary destruction of the product(s) does not preclude any appropriate
legal action.
Furthermore, I/we understand that the election to voluntarily destroy the above referenced product(s) waives any claim for an
allowance in duties under Customs law or regulation.
The statements herein are made in full knowledge of the provisions of the U.S. Code, Title 18, Section 1001, which makes it a
criminal offense to make a willfully false statement or misrepresentation to any department or agency of the United States as to any
matter within its jurisdiction.
12. Signature of Establishment Representative

14. Date

13. Title

Destruction Observed By:
(This form is only applicable to destruction of product witnessed by FSIS personnel)
15. Signature of Inspection Program Personnel
FSIS 9840-4 (01/31/2023)

16. Title

17. Circuit

REPLACES FSIS FORM 9840-4 (08/2013), WHICH MAY BE USED UNTIL EXHAUSTED

18. Date

INSTRUCTIONS FOR COMPLETION OF FSIS FORM 9840-4
(Completed by Importer/Broker/Agent)

Note: This form is only applicable to destruction witnessed by FSIS personnel (e.g., denaturing).

Open Line/Space: Name of importer/broker/agent
1. Inspection Certificate Number: Enter the inspection certificate number from the import application
2. Customs Entry Number: Enter the customs entry number from the import application
3. Country of Origin: Enter the name of the country from the import application.
4. Processing Establishment Number: Enter the processing establishment number that produced the product from the import
application
5. FSIS Establishment Number: Enter the FSIS establishment number assigned to the import establishment where the product was
reinspected from the import application
6. Lot Number: Enter the lot number from the import application
7. Description of Product: Enter the description of the product from the import application.
8. Shipping Marks/Identification: Enter the unique identifying mark certified on the foreign health certificate and which is applied to
the product shipping containers in the foreign country from the import application
9. Date Refused: Enter the date the product was refused entry from the refused entry notification
10. Quantity: Enter the quantity from the refused entry notification
11. Weight: Enter the refused weight in pounds from the refused entry notification
12. Signature of Establishment Representative: Establishment representative who is authorizing destruction of the refused entry
signs here.
13. Title: Title of establishment representative.
14. Date: Enter the date signed.

(Completed by FSIS Inspection Program Personnel)

15. Signature of Inspection Program Personnel: The FSIS inspection program personnel who witnesses the destruction signs here.
16. Title: Title of inspection program personnel.
17. Circuit: Enter the number of the circuit in which the import facility is located.
18. Date: Enter the date the refused entry notification was signed.