Form LS-54-1 Pork Promotion, Research, and Consumber Information Orde

FORM APPROVED - OMB NO. 0581-NEW

REPRODUCE LOCALLY. Include from number and date on all reproductions.

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

PORK PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER
REQUEST FOR REFERENDUM
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to
a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection
is 0581-NEW. The time required to complete this information collection is estimated to average 12 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national
origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply
to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print,
audiotape, etc.) should contact USDA's Target Center at 202-720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence
Avenue, SW, Washington, DC 20250-9410 or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

CERTIFICATION STATEMENT
I HEREBY CERTIFY that I am a pork producer, producer entity, importer, or importer entity that has been engaged in the production of
hogs or pigs in the United States for sale in commerce or importation of hogs, pigs, pork or pork products between January 1, 2007, and
December 31, 2007, and that I am at least 18 years of age on or before December 31, 2007. I am requesting a referendum only once
in the same capacity registered. I FURTHER CERTIFY that the supporting documentation that I am providing along with this form is
true, complete, and correct to the best of my knowledge and belief. Failure to provide supporting documentation showing that a pork
assessment was paid and complete and sign this form will invalidate the request.
NAME OF INDIVIDUAL PRODUCER, PRODUCER ENTITY, IMPORTER, OR IMPORTER ENTITY (Print)

ADDRESS (Street, P.O. Box, or Route No., City, State, ZIP Code)

TELEPHONE NUMBER (Including Area Code)

IMPORTANT:

COUNTY

Sign and date this form if you wish to request a referendum on the Pork Promotion, Research, and Consumer Information Order.

SIGNATURE OF PRODUCER, PRODUCER ENTITY, IMPORTER, OR IMPORTER ENTITY

TITLE (If applicable)

LS-54-1 (01-08)

DATE