Ingredient Report

Form Approved
OMB No. 0920-0210
Exp. 09/30/2012
Recommended Ingredient Reporting Format - CSTHEA
Please attach additional pages if necessary

Date
Office on Smoking and Health
Attn. FCLAA Program Manager
4770 Buford Hwy., NE, MS K-50
Atlanta, GA 30341
This ingredient report is being submitted pursuant to the Federal Cigarette Labeling and
Advertising Act (FCLAA), 15 U. S.C. §1335 (a) Public Law 89–92.

Company Name(s)*

Brand(s)†

*If this Ingredient Report is submitted by a designated individual or entity on behalf of a cigarette manufacturer,
packager, or importer, the form must specify on whose behalf the submission is being made.
†Inclusion of the brand name and product type for ingredients is not required under CSTHEA.

Form Approved
OMB No. 0920-0210
Exp. 09/30/2012
Ingredient Name
¶

¶ CAS Registry Number§