Electronic versions available at Page 1 of 1
►Oregon Tilth Client: Use this Affidavit for any nutrient (vitamins or minerals) you would like to use in your certified products. Forward this Affidavit to your material manufacturer. They must fill out and sign this form.
►Material Manufacturer: Fill out this form so OTCO may review this material for the Oregon Tilth certified client’s use. In addition, please attach either a copy of the label disclosing all material ingredients, a copy of the MSDS (if all ingredients are disclosed), or a current statement that discloses all ingredients. Attached
NOP 205.105(e) and 205.301(f)(1), in order for a product to be sold as “100% organic,” “organic,” or “made with organic (specified ingredients or food group(s)),” the product must be produced and handled without the use of excluded methods. (genetically modified organisms). Where non-agricultural nutrients (which include vitamins) are used as either ingredients in processed products, or as feed additives or medical treatments in organic livestock production, the nutrients must be free from modified DNA and/or the proteins from genetically modified DNA.1.1NUTRIENT INFORMATIONPlease fill out the company name and contact information for the manufacturer.
Type of Nutrient:Manufacturer Business Name:
Address: / City: / State: / Zip:
1.2 DECLARATIONThe nutrient listed above conforms to the following criteria:
A. Irradiation was NOT used in the production of this material. / True False NAB. Sewage sludge was NOT used in the production of this material. / True False NA
C. For livestock feed additives ONLY, the material was NOT produced with any mammalian, or poultry by-products (for mammal, or poultry feed). / True False NA
D. The final product (including carriers, diluents, antioxidants) does not contain modified DNA and/or the proteins derived from genetically modified DNA. This has been verified by the following measures: (check all that apply)
Traceability/Identity Preserved SystemPCR (Polymerase Chain Reaction) Testing
Independent Audit Equivalent declaration from supplier or ingredient suppliers
Other (Production Techniques, Types of Raw Materials and Processing Aids used)
If other, explain: / True False NA
2525 SE 3rd Street, Corvallis, OR 97333, 503-378-0690 | 1-877-378-0690 |
Declaration for Nutrient Vitamins rev. 5/30/14
/ DECLARATION FOR NUTRIENT VITAMINS AND MINERALS / DNVElectronic versions available at Page 1 of 1
1.3The statements regarding the material produced by my company are true to the best of my knowledge.
Manufacturer Representative Name (please print) / Representative Signature / DateTitle/Position with Manufacturer
2525 SE 3rd Street, Corvallis, OR 97333, 503-378-0690 | 1-877-378-0690 |
Declaration for Nutrient Vitamins rev. 5/30/14