Data Elements Required for FDA Prior Notice Submission This Form must be Completed in english

Te U.S. Food and Drug Administration (FDA) regulations require that:

1.- All forein facilities that manufacture, process, pack or hold food for human or animal consumption in the United States register with
theFDA
2.- Prior notice is Submitted to FDA for shipments of food for human or animal consumption in the United States, and for certain
shipments transiting the USA

If you would like FedEx to transmit the Prior Notice and your behalf, please provide the following data elements on your shipmen
documentation or on this form. If you have already filed the FDA Prior Notice, provide the Prior Notice Confirmation No(s) for

FedEx Awb No. 3916 3126 5939 Date of Shipment 07 / APRIL / 2020

Submitter/Shipper - Person providing this Information REMITENTE / DATOS

Company Name Name IRMA MOJICA LOPEZ
Adress Title
CALLE SAN MARTIN 31, COL. CENTRO
SAN IGNACIO CERRO GORDO, JAL. Email
MEXICO
Country of Export MEXICO Phone No. 3481031466
* Registration Number Fax No. N/A

Importer/Ultimate Consignee (DESTINANTARIO / DATOS

Company Name Name LILIANA LOPEZ

1554 MORRIS AVE Title
LINCON PARK, MI
Email
48146
Phone No. 3133042533

Fax.No N/A

Commodity Information - provide the following for EACH food item in the shipment

Items
• BREAD MADE OF FLOUR - CARAMEL-CANNED FRUIT – TRADICIONAL COCONUT CANDY-
MARSHMALLOWS- JELLY – TRADITIONAL CHOCOLATE-MILK CANDY PILLOWS SWEET OF AMARANTO

Description (Food Item Common, Usual or Market Name)

HOMEMADE FOR PERSONAL CONSUMTION
HTS Code (If Available) Lot/Code# (If applicable)
Quantity 11.5 KG Unit of Measure KILOGRAMS
Product Code (If Available) Country of Production MEXICO
Type * Manufacturer registration Number (If Applicable)
Grower Manufacturer
Name Type of Packanging
Address
PAPERBOARD