Letter of Authorization (LOA) for your customer
Withdrawal of Letter of Authorization
See the next page for the template. Information to be filled in, including notes about that information, is in brackets.
Date: [Enter the date of this submission]
DMF#: [Enter the DMF number]
Holder: [Enter the DMF holder’s name]
Subject (Title): [Enter the subject (title) of the DMF as it appears on the DMF List, available on the DMF web site at ]
Submission Type: Withdrawal of Letter of Authorization
Dear DMF staff:
[DMF HOLDER] hereby withdraws authorization for [AUTHORIZED PARTY] to incorporate by reference information regarding [DMF number in its entirety or an item in DMF number] into any [application] filed by [authorized party]. The original letter of authorization was submitted on [date of the LOA]. The authorized party has been notified of this withdrawal of authorization.
Sincerely,
[Signature of responsible official]
[Name of responsible official]
[Responsible official’s title]
[Responsible official’s company (i.e., DMF holder or agent)]
[Responsible official’s telephone number]
[Responsible official’s fax number]
[Responsible official’s email address]
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