Attachment A-04 Form 8570-5

Form Approved. OMB No. 2070-NEW
Expiration: xx/xx/xxxx
Please Read All Instructions before Completing this Form (Form must be typed)

United States
ENVIRONMENTAL PROTECTION AGENCY
Office of Pesticide Programs (Mail Code: 7504P)
Washington, DC 20460

Notice of Supplemental Distribution of a Registered Pesticide Product
Instructions
Registrants may distribute or sell the products under another company’s name and address instead of (or in addition to) their own after
obtaining final registration. Such distribution and sale is termed “supplemental distribution” and the product is referred to as a
“supplemental registration” or “distributor product”. The distributor, also known as a “sub-registrant,” is considered an agent of the
registrant. Both the registrant and the distributor may be held liable for violations pertaining to the distributor product.
A Notice of Supplemental Distribution of a Registered Pesticide Product must be submitted by the basic registrant for each distributor
product. The basic registration number and the distributor company number must be shown. If a potential distributor does not have a
company number assigned, the registrant should have the distributor review the information
at: https://www.epa.gov/pesticide-registration/pesticide-registration-manual-how-obtain-company-number-and-register-official
or submit a written request on the distributor company’s letterhead and mail to the address above prior to submitting this form to the
agency. The completed form must have the concurrence and signature of both the registrant and the distributor.
EPA Registration Number of Product
Distributor Company Number

Note: Do not submit distributor product labels
Name of Registered Product (basic, EPA-accepted product name)

Distributor Product Name

Name and Address of Distributor (Type; include ZIP code)

Read All Conditions Before Signing

1. The distributor product must have the same composition as the basic product.
2. The distributor product must be manufactured and packaged by the same person who manufactures and packages the registered
basic product.

3. The labeling for the distributor product must bear the information as that of the registered product. Specific claims may be omitted
from the distributor’s label provided that no other changes are necessary.

4. The product must remain in the manufacturer's unbroken container.
5. The label must bear the EPA registration number of the basic product, followed by a hyphen and the distributor's company number.
6. Distributor product labels must bear the name and address of the distributor qualified by such terms as "packed for ...”,
"distributed by ... ", or "sold by ..." to show that the name is not that of the manufacturer.

7. All conditions of the basic registration apply equally to distributor products. It is the responsibility of the basic registrant to see that
all distributor labeling is kept in compliance with requirements placed on the basic product.
Distributor
We intent to market our product under the Distributor Product Name specified above, subject to the conditions specified in this Notice.
Signature and Title of Distributor

Date

_______________________________________________________________

___________________________

Registrant
I agree that the distributor named above may distribute and sell the Distributor Product specified above, subject to the conditions specified in
this Notice.
Signature and Title of Registrant

Date

_______________________________________________________________

___________________________

EPA Form 8570-5 (Rev. 2-13) Previous editions are obsolete.

PAPERWORK REDUCTION ACT NOTICE
This collection of information is approved by OMB under the Paperwork Reduction Act, 44
U.S.C. 3501 et. seq. OMB Control No. 2070-NEW. Responses to this collection of information
are mandatory 40 CFR 132. An agency may not conduct or sponsor, an a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control
number. The public reporting and record keeping burden for this collection of information is
estimated 19 minutes per response. Send comments on the Agency’s need for this information,
the accuracy of the provided burden estimates and any suggested methods for minimizing
respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection
Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed form to this address.