Attachment A-07 Form 8570-27

OMB Control Nos.
2070-NEW
Expiration Date
XX/XX/XXXX

United States

Environmental Protection Agency
Washington, DC 20460

Formulator’s Exemption Statement
(40 CFR 152.85)

Applicant’s Name and Address

EPA File Symbol/Registration Number

Product Name

Date of Confidential Statement of Formula (EPA Form 8570-4)

As an authorized representative of the applicant for registration of the product identified above, I certify that:
(1) This product contains the following active ingredient(s):

(2) Of these, each active ingredient listed in paragraph (4) is present solely as the result of the use of that active ingredient in the manufacturing,
formulation or repackaging another product which contains that active ingredient which is registered under FIFRA Section 3, is purchased by
us from another person and meets the requirements of 40 CFR section 158.50(e)(2) or (3).
(3) Indicate by checking (A) or (B) below which paragraph applies:

 (A) An accurate Confidential Statement of Formula (EPA FORM 8570-4) for the above identified product is attached to this statement.
That formula statement indicates, by company name, registration number, and product name, the source of the active ingredient(s) listed in
paragraph (1).
OR



(B) The Confidential Statement of Formula (CSF)(EPA Form 8570-4) referenced above and on file with the EPA is complete, current, an
accurate and contains the information required on the current CSF.

(4) The following active ingredients in this product qualify for the formulator’s exemption.

Source
Active Ingredient

Signature

EPA Form 8570-27

Product Name

Name and Title

Registration Number

Date

Copy 1 – EPA
Copy 2 - Applicant copy

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 158. 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 1.5
hours 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.

EPA Form 8570-27
Reverse Copy 1 - EPA Copy 2 - Applicant copy