AMS-4 CA FMMO- Milk Producer's Ballot

Approved Form
OMB No. 0581-0300

DESCRIPTIONS OF THE TERMS AND CONDITIONS OF THE ORDER,
AS PROPOSED, REGULATING THE HANDLING OF MILK
IN THE XXX MARKETING AREA
SUMMARY OF THE ORDER, AS PROPOSED
(to be filled in with description of Proposed Order)

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 0581-0300. The time
required to complete this information collection is estimated to average 15 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.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies,
offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color,
national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status,
income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity
conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with
disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.)
should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination
complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html
and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: mail: U.S. Department of Agriculture Office of the Assistant
Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; fax: (202) 690-7442; or email:program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.

YOUR BALLOT IS PRINTED ON THE REVERSE OF THIS SHEET

Approved Form
OMB No. 0581-0300

MILK PRODUCER'S BALLOT
XXX MARKETING AREA
A copy of the XXX Federal Milk Marketing Order, as proposed, upon which you are voting
along with the Notice of Referendum are included with this ballot. Additional copies of the
FMMO, as proposed, can be secured from the Referendum Agent at the address shown on
the XXX.
INSTRUCTIONS - Fill in ALL blank spaces, indicate your approval
or disapproval by placing an "X" in the appropriate box, place
your ballot in the enclosed self-addressed stamped envelope, and
mail your ballot so that it will be postmarked on or before the date
specified in the XXX.
I,

, hereby certify that I am a dairy farmer. I also
Print Your Name Here

certify that, during the month/year ______________, I was a producer of milk as defined in
the proposed order regulating the handling of milk in the XXX marketing area.
I further certify that I currently deliver or ship Grade A milk to the plant of
located in

.
City & State

Plant Name

Signature -- Do Not Print

Print Your Mailing Address

Producer Number or Patron Number -- If Known

Print Your City, State, Zip

Do you approve the issuance by the Secretary of Agriculture of the order
as amended, regulating the handling of milk in the XXX marketing area?

Place An "X" In One
Box Only

YES

NO

THIS BALLOT AND THE INFORMATION CONTAINED THEREON WILL BE KEPT CONFIDENTIAL

A DESCRIPTION OF THE ORDER MAY BE FOUND ON THE REVERSE SIDE