STATEMENT OF INGREDIENTS AND ADDITIVES

(To be printed on letter Head of Company /Firm)

1. Name of the Food Product:

2. Type of Food Product: Health Supplement / Nutraceutical /FSDU/FSMP other than Infants/Food
with added probiotic ingredients/Food with added prebiotic ingredients/Specialty Food
containing plant or botanical ingredients with safe history of usage. (Tick any one)
3. Food Category No:
4. Target Group (Age and Gender):
5. Target Physiological condition:
6. Product Format: Tablet/Capsule/Syrup/Any Other_____________
7. Recommended serving size and no.of recommended serves per day:
8. Any type of Claims to be made on the label:

Ingredients:

S.N Ingredients Schedule under Quantity of Purity Criteria

O (Name of the
Ingredients )
Nutraceutical ingredient Used in adopted
Regulations in which the product/serving
the ingredient is size
permitted for (In addition, in case
use/Product of micronutrients,
Approval Copy percentage of RDA
to be declared)

Additives:

S.NO Name of the Food Schedule under INS No Level of additives in

Additives or Group Nutraceutical the product
Regulations in which
the ingredient is
permitted for use
(Schedule
VA/VF)/Product
Approval Copy
 I declare that:

1. No hormones or steroids or psychotropic ingredients have been used in the above food
product.
2. The ingredients and additives used in the food product are in accordance with the type
of food product/category as mentioned in the Nutraceutical regulations.
3. Nutrients added to the product comply with the respective Recommended Daily
Allowance specified by ICMR/Codex Alimentarius Commission.
4. The product is not a more combination of vitamins and minerals.
5. No claim regarding prevention, treatment or cure of any disease or referring to such
properties shall be made for the said food product.
6. The product is not a drug as defined under drugs and cosmetics Act, 1940

Signature of FBO/Authorized Signatory with seal