AMS-4 CN Labeling Application

_{OMB No. 0581-0261}

_{Exp. XX/XX/XXXX}

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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 OMB-0581-0261. The time required to complete this information collection is estimated to average 75 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and the collection of information.
U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE APPLICATION FOR CHILD NUTRITION (CN) LABELING PROGRAM	1. AGENT NAME, ADDRESS, TELEPHONE NO. (If using an Agent, complete this block, otherwise leave blank.)	2. FOR USDA USE ONLY	3. ESTABLISHMENT NUMBER/FOREIGN COUNTRY (If applicable)
			4. CN NUMBER
5. NAME OF PRODUCT
6. PRODUCT FORMULA				☐ PERCENT ☐ WEIGHT (No Fractions)
TOTAL (Percent must total 100%)

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7. PROCESSING PROCEDURES (Approval of the label application does not convey approval of the processing procedures)
8. ITEMS THAT MUST BE MONITORED IN QUALITY CONTROL PROGRAM
9. SIGNATURE OF APPLICANT OR AGENT		10. DATE
11. NAME AND ADDRESS OF FIRM	12. CONDITIONS APPLYING TO USE OF LABELS (FOR USDA USE ONLY)

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PRODUCT NAME

THIS SHEET IS BEING USED FOR ADDITIONAL INFORMATION REQUIRED IN BLOCK(S)

Non-Discrimination Policy: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

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