Form See List See List See List

Attachment A:

Forms that are commonly associated with Data Call-ins – available
electronically as a PDF file on the internet
at: http://www.epa.gov/pesticide-registration/pesticide-registrationmanual-chapter-20-forms-and-how-obtain-them#epa unless otherwise
noted.
EPA Form No. 8570-4 - Confidential Statement of Formula
EPA Form No. 8570-27 - Formulator's Exemption Statement
EPA Form No. 8570-28 - Certification of Compliance with Data
Gap Procedures
EPA Form No. 8570-32 - Certification of Attempt to Enter into an
Agreement with Registrants for Development of Data Form
EPA Form No. 8570-34 - Certification with Respect to Citation of
Data Form
EPA Form No. 8570-35 - Data Matrix Form
EPA Form No. 8570-36 - Summary of the Physical/Chemical
Properties Form
EPA Form No. 8570-37 - Self-Certification Statement for the
Physical/Chemical Properties
The remaining forms are computer generated and uniquely prepopulated and sent directly to individual registrants. Samples of
these forms have been this attachment as part of the EPA-HQOPP- 2016-0109 docket.
EPA Form No. 6300-3 - Requirements Status and Registrant’s
Response.
EPA Form No. 6300-4 - Data Call-In Response Form.

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, D.C. 20460

Form Approved.
OMB Control Nos.
2070-0057; 2070-0107;
2070-0122; 2070-0164

DATA CALL-IN RESPONSE

Paperwor k Reduction Act Notice: The public reporting bu rden for this collection of information is estimated to average XXXX h our per resp onse for reregi strati on and speciall review acti vities, including time for reading the
instructions and completing the necessary forms. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to: Director, Collection Strategies
Division (2822T), U.S. Environmental Protection Agency, Washington, DC 20460. Do not send the form to this address.
INSTRUCTIONS: Please type or print in ink. Please read carefully the attached instructions and supply the information requested on this form. Use additional sheets if necessary.
1. Company Name and Address

2. Case # and Name

3. Date and Type of DCI

Chemical # and Name

4. EPA Product Registration

5. I wish to cancel this
product registration
voluntarily

6. Generic Data
6a. I am claiming a Generic Data
Exemption because I obtain the
active ingredient from the source
EPA registration number listed
below.

7. Product Specific Data
6b. I agree to satisfy Generic
Data requirements as indicated
on the attached for entitled
“Requirements Status and
Registrant’s Response.”

7a. My product is an MUP and I
agree to satisfy the MUP
requirements as indicated on the
attached for entitled “Requirements
Status and Registrant’s Response.”

7a. My product is an EUP and I
agree to satisfy the EUP
requirements as indicated on
the attached for entitled
“Requirements Status and
Registrant’s Response.”

8. Certification
I certify that the statements made on this form and all attachments are true, accurate and complete. I acknowledge that any knowingly false or misleading statement may be punishable
by fin or imprisonment or both under applicable law.

9. Date

Signature of Company’s Authorized Representative
10. Name and Title (Please Print or Type)

EPA Form 6300-4

11. Phone Number