Section 190.APPENDIX C Disclosure Statement: Distributor

For purposes of this disclosure, non-halal means food that this establishment does not represent to be halal.

Name of Distributor:

Please check all that apply.

A. General Disclosure

	This establishment distributes only halal foods.
	This establishment distributes both halal and non-halal foods.
	This establishment distributes only meat and poultry as halal.
	This establishment makes no representation as to the halal status of its foods other than that which appears on the package label of prepackaged food.
	Meat distributed at this establishment is kept in the original package.
	Meat distributed at this establishment is repackaged.
	Meat repackaged at this establishment may be from different sources.
	This establishment is under the supervision of the following halal certifying entity:
	Name:
	Address:

	Telephone Number:

B. Meat and Poultry

Meat offered for sale at this establishment has been purchased from the vendors listed below who made the following representations. Each vendor must have Part B (Meat) filled out individually:

Name:
Address:

Telephone Number:
IDOA halal registration number (if applicable):

	The animal was fed only 100% vegetarian feed, organic feed, or Amish feed, none of which contain any animal by-products.
	The animal was not treated with hormones.
	The animal was alive at the time of slaughter.
	The animal was not stunned before slaughter.
	The animal was hand-slaughtered with a sharp knife.
	The knife used during the slaughter was sharpened/cleaned after each animal.
	The animal was facing Mecca when slaughtered.
	The animal was slaughtered by a person who represents him/herself as a Muslim.
	The slaughterer pronounced an Islamic benediction while performing the slaughter.
	The animal was slaughtered with a swift, deep incision on the neck that cut the jugular veins and carotid arteries on both sides and also the trachea and esophagus.
	The spinal cord was not severed at the time of slaughter.
	Only non-animal derived/non-alcohol based cleansers and sanitizers were used to wash/clean the equipment.
	The animal was drained of blood following slaughter.
	The animal slaughtered to be sold as halal was stored in a cooler or freezer that contained only meat or poultry to be sold as halal.
	If any additional steps or procedures were performed, they were:




	This establishment distributes meat or poultry labeled halal or zabiha halal from a federally inspected meat packaging plant.
	This establishment distributes meat or poultry that has not been identified as halal or zabiha halal by the slaughterhouse.
	Pork or pork products are not sold at this establishment.

Poultry offered for sale at this establishment has been purchased from the vendors listed below who made the following representations. Each vendor must have Part B (Poultry) filled out individually:

Name:
Address:

Telephone Number:
IDOA halal registration number (if applicable):

	The poultry was fed only 100% vegetarian feed, organic feed, or Amish feed, none of which contain any animal by-products.
	The poultry was not treated with hormones.
	The poultry was alive at the time of slaughter.
	The poultry was not stunned before slaughter.
	The poultry was slaughtered by mechanical means.
	The poultry was hand-slaughtered with a sharp knife.
	The knife used during the slaughter was sharpened/cleaned after each use.
	The poultry was facing Mecca when slaughtered.
	The poultry was slaughtered by a person who represents him/herself as a Muslim.
	The slaughterer pronounced an Islamic benediction while performing the slaughter.
	The poultry was slaughtered with a swift, deep incision on the neck that cut the jugular veins and carotid arteries on both sides and also the trachea and esophagus.
	The spinal cord was not severed at the time of slaughter.
	Only non-animal derived/non-alcohol based cleansers and sanitizers were used to wash/clean the equipment.
	The poultry was drained of blood following slaughter.
	The poultry slaughtered to be sold as halal was stored in a cooler or freezer that contained only meat or poultry to be sold as halal.
	If any additional steps or procedures were performed, they were:




	This establishment purchases only meat or poultry labeled halal or zabiha halal from a federally inspected meat packaging plant.
	This establishment sells meat or poultry that has not been identified as halal or zabiha halal by the slaughterhouse.
	Pork or pork products are not sold at this establishment.

C. Food Products Prepared On Site

	Prepared food labeled or represented as halal does not contain or use any ingredients from an animal not represented as halal by the slaughterhouse.
	Prepared food labeled or represented as halal does not contain any product containing pork.
	Prepared food labeled or represented as halal does not contain any alcohol.
	No alcohol is used in the preparation of any prepared food represented as halal.

D. Food Packaging

	Food packaging materials have been certified as halal by the following halal certifying entity:
	Name:
	Address:

	Telephone Number:

E. Cleaners and Sanitizers

Only non-animal derived/non-alcohol based cleansers and sanitizers are used to wash/clean the equipment.

F. Certification by Livestock Producer

I certify that the above information is correct.


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Printed Name
Business Name
Address
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