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Ingredient Information Request Form

The following is a request for technical information on materials supplied to Dr Pepper

Snapple Group. Please complete each section or provide the requested information, sign
and return to the requestor via email within 10 days of receipt. Dr Pepper Snapple Group
requires this information for all ingredients in advance of testing.

The Optiva number and supplier name will automatically appear on every page by following
these instructions. Double click on the greyed box that says “Optiva Number” or “Supplier
Name” on page 2 of this document. Enter in the appropriate information in the default text
field. Click OK. Press “Ctrl” and “a” at the same time. Then press F9. The Optiva Number
and Supplier Name should now appear on every page in the upper right hand corner of the
document. Please follow the above instructions to make any additional changes. The
header will not automatically update.

Please send DPSG the following documents in electronic format:

1) This document for a single ingredient with all fields completed

2) Certificate of Analysis (for lot number being evaluatedor example)
3) Specification and/or Technical Data Sheet
4) Kosher Certificate
5) MSDS (not required for juices)

6) Natural Flavor Certificate (if applicable)

7) ‘Natural’ ingredient documentation (if applicable)

8) Max Use Level – flavors and flavor modifiers only

9) Compositional breakout including the name of each component, CAS Number,
and targets or ranges of each component

Please use the following contact with any questions related to this information request:

DPSG Requestor Liliana Rodríguez G.

Title Quality Leader
Address Calle 5 No 24 C Fraccionamiento Alce Blanco
Telephone Number (52) 552122 0400
Fax
Email Lrodriguez@dva.mx

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1. Ingredient Description and Supplier Information

DPSG Optiva Number Optiva Number

Supplier (Name of Company) DVA Mexicana

Supplier Material Description Ac. Tanico

Supplier Material Number F-00104

Location of Production Sites Belgium

Country of Origin for the Finished

Belgium
Ingredient (include all that apply)

2. Regulatory Status
For regulatory status and use limits, please provide the citation of the applicable regulation
for the use of this ingredient including each component if the ingredient is a blend, in
beverage and processed fruit products (e.g., 21 CFR 184.1033 or US FDA GRAS Notification
Number (GRN 208)). For non-public (e.g. Self GRAS)determinations please include the
supporting documentation when returning this form to Dr Pepper Snapple Group. In regions
where the ingredient is not approved, please enter “not approved.”

Ingredient/Component
Common and Usual Name Regulatory Citation
(CFR, GRN, FEMA, Self GRAS)
US Canada Mexico
ISO 9001, 21 CFR Sec. 184.1097. FEMA
1 KOSHER, ISO 3049, EC Regulation No.
22000, GMP 1907/2006
Anexo II Aditivos con diversas
21 CFR Sec. clases funcionales que pueden
2 184.1097 ser utilizados de acuerdo con las
BPF; Anexo X Coadyuvante de
elaboración
3

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3. Allergens and Sensitivities/Intolerances Information

Complete the following table regarding the presence of allergens and
sensitivities/intolerances. Please refer to the FDA and Canadian regulations,
including any additional Guidance and Questions and Answers when completing this
section:

Allergens Absent Present

Wheat and wheat products X
Crustacean shellfish and products X species:
Eggand egg products X
Fishand fish products X species:
Milkand milk products X
Peanutsand peanut products X
Soybeanand soy products with the exception of
highly refined soy oil X

Tree nutsand tree nut products (includes coconut) X variety:

Mollusksand mollusk products X species:
Mustard seed and mustard products X
Sesame seedsand products X

Sensitivities/Intolerances Absent Present

Gluten sourced from wheat, rye, barley, triticale
and oat X variety:

Juices from Grapefruit, tangelos and/or Seville

orange X

Sulfites
(If present, indicate quantity in ppm) X level: ppm

Quinine
(If present, indicate quantity in ppm) X level: ppm

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4. GMO Information

Parameter Yes No Unknown

Is the material derived
A) from genetically modified
sources?
If yes, go to 4B If no, continue to section 5

B) If 4A is ‘yes,’ does the

material contain
detectable GM protein?

5. Physical & Chemical Parameters

Please enter the quantity, or value for the parameter requested.

Minimu Targe Maximu Unit

Parameter
m t m s
Apparent Density at 20oC
 Required for all ingredients
0.35 0.45 kg/L
 Substitute with bulk density
for powders

Specific Gravity at 20oC g/

 Required for juices cm3

Solids
 Required for all liquid %
sweeteners

Brix, Refractometer at 20°C

 Required for bulk sweeteners %
and juices

Brix, Refractometer@20°C, Corrected

for Citric Acid %
 Required for citrus juices
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6. Nutrition Information
Please enter the quantity of nutrient present and identify if the value was derived through
calculation or by analysis. Please complete for allrequired nutrients.

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 Calculated or
“as is” basis Units
Required Nutrients Analytical
(no rounding) per 100 g
(C or A)
Calories 0 KCAL
Total Carbohydrates 0 g
Protein 0 g
Total Sugars 0 g
Alcohol as Ethanol (w/w) 0 g
Fat 0 g
Saturated Fat 0 g
Trans Fat 0 g
Polyunsaturated fat 0 g
Monounsaturated fat 0 g
Cholesterol 0 mg
Total Dietary Fiber 0 g
Soluble Fiber 0 g
Insoluble Fiber 0 g
Sodium 0 mg
Potassium 0 mg
Vitamin A 0 IU
Vitamin C 0 mg
Calcium 0 mg
Iron 0 mg
Ash 0.01 %
Moisture 7 %
Other Known Nutrients: 0

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7. Flavors and Flavoring Ingredients

The following information is required for flavors and flavoring ingredients only. This
information is not required for any other ingredients (i.e. juices).

General Flavor Information

Are all the flavoring components FEMA GRAS or Yes No

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 General Flavor Information
FDA GRAS?
N.A.
What is the regulatory maximum use level for
this flavor or flavoring ingredient (if
ppm
applicable)?

For finished product labeling purposes, please check the description that applies and
complete characterizing flavor information:

Please list
characterizing flavors

Natural Flavor
N.A.
(All Flavor Ingredients are Natural Characterizing)

Natural with Other Natural Flavors

N.A.
(WONF)

Natural and Artificial Flavor N.A.

Artificial Flavor N.A.

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8. Compositional Breakout
Information regarding compositional breakout is required for all ingredients to make
determinations about finished product labeling. Please list each component in the
ingredient and the use level or concentration. The sum of the concentration for all

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components should equal 100%. If the ingredient is composed of only one component,
please list that component and that the concentration is equal to 100%.

CAS Number Target °Brix

Concentration
Component / Ingredient (if applicable) (Juice Only)
(%)

N.A. N.A. N.A. N.A.

Total 100%

9. Supplier Contact Information

By completing and submitting this information, the supplier agrees that the information
provided is correct. The supplier is responsible for notifying Dr Pepper Snapple Group of
any changes to this ingredient.

Name of Company DVA Mexicana S.A. de C.V.

Name of Individual Completing Form Liliana A. Rodríguez Gerón

Date May 21, 2014

Telephone Number (52) 55 2122 0400

Address Calle 5 No 24 Local C

Email Address Lrodriguez@dva.mx

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