Form 2514 Notice of Discontinuance of Commercial Distribution of C

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
College Park, MD 20740-3835

Form Approved : OMB No. 0910-0030
Expiration Date: February 29, 2012
NOTE: This report is authorized by Public Law 21 U.S.C. 371(A); 21 CFR
720. While you are not required to respond, your cooperation is needed to
make the results of this voluntary program comprehensive, accurate, and
timely.

NOTICE OF DISCONTINUANCE OF COMMERCIAL DISTRIBUTION
OF COSMETIC PRODUCT FORMULATION
(In accordance with 21 CFR 720)

Public reporting burden for this collection of information is estimated to average 6 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. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer (HFA-710)
5600 Fishers Lane
Rockville, MD 20857
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.

INSTRUCTIONS: Read instruction booklet before completing. Type entries in capital letters.
1. FDA CPIS NO.

2. FILING DATE

F

-

3. DISCONTINUANCE DATE

-

-

-

4. NAME OF MANUFACTURER/PACKER/DISTRIBUTOR (On Label)

5. BRAND NAME AND NAME OF COSMETIC PRODUCT*

6. COMMENTS (if any)

*Submission of Form FDA 2514 will discontinue an entire Cosmetic Product Ingredient Statement. All Brand Names reported under this CPIS
number will be discontinued. If more than one cosmetic product has been filed under the Cosmetic Product Ingredient Statement and you wish to
delete one or more of the Brand Names, but not all of them, file an amended Form FDA 2512 deleting those cosmetic products that are no longer
manufactured.
7. TYPED NAME AND TITLE OF AUTHORIZED INDIVIDUAL

FORM FDA 2514 (6/09) PREVIOUS EDITION IS OBSOLETE

8. SIGNATURE AND DATE

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PSC Graphics: (301) 443-1090

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