5020-4 Recall Distribution Information Template

OMB Number: 0583-0135 Expiration Date: XX/XX/XX XXXX-X

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 0583-0135. The time required to complete this information collection is estimated to average 60 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.

FSIS Recall Distribution Information Template:

Please enter consignee information in the following template. Items with (*) are required. Either a phone number or email for each location is required (**)

Establishment number on Product

Product Received by Consignee

Consignee Name*

Street Address Line 1*

Street Address Line 2

City*

State*

Zip Code (5 digit)*

Type of Business* (select from dropdown options)

If Type of Business is "Other", enter description

Distributor product was received from

Amount received in pounds (numerical values only)

Email**

Phone Number**

Comments (4,000 character limit)

Contact Person First Name

Contact Person Last Name

Contact Person Title

Contact Person Phone

Contact Person Email