LPS-1 Egg Research & Promotion Registration, Ballot, and Certi

FORM APPROVED. – OMB NO. 0581-0093
UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

EGG RESEARCH AND PROMOTION ORDER

REGISTRATION, BALLOT, AND CERTIFICATION

INSTRUCTIONS:
Please complete all information and forward in the enclosed
envelope to the Director, Research and Promotion Division; Livestock, Poultry, and Seed
Division, AMS, USDA; Street; City, State Zip. Mark an “X” in appropriate blocks.
Completed ballots must be postmarked not later than
. Incomplete
ballots or ballots received after
will be invalid and will not be counted
for any purpose in the referendum. The information you provide below regarding the
number of laying hens, location, egg production figure, and how you voted shall be kept
confidential.

REGISTRATION
NAME OF EGG PRODUCER (Print or type)

STREET, RURAL ROUTE, OR R.F.D. NUMBER

(If corporation, partnership, estate, etc., list name of business entity. If
individually owned, list last name first, first name, and middle initial of sole
Proprietor.)

COUNTY OR PARISH

CITY OR TOWN, STATE, ZIP CODE

1.

At any time during the period
own over

2.

through

did you
YES

laying hens, excluding hens primarily engaged in the production of hatching eggs?...

State average number of laying hens owned during the period

NO

through

. List location of such laying hens on the reverse side of this form……
3.

State total number of 30-dozen cases of eggs produced by laying hens during the period
through

NOTE:

.......................................................

If you do not have a record of the number of cases of eggs produced, use the following computation which is based on the
national average: Multiply average number of laying hens owned times a factor of 0.174.
EXAMPLE; 300,000 laying hens x 0.174 = 52,200 cases
BALLOT

Do you favor
.

YES

NO

CERTIFICATION STATEMENT
I hereby certify that I am an egg producer as defined in the order, that during the period

through

, I was an egg producer as defined in the order, and that the information contained in this Registration,
Ballot, and Certification is true, complete, and correct to the best of my knowledge and belief and is made in good faith.

NAME (Print or type)

SIGNATURE*

DATE

*If the vote is cast on behalf of a corporation, estate, or any person other than an individual, my signature certifies
that I have the authority to take such action. In such case, provide the following information:

NAME OF CORPORATION, PARTNERSHIP, ESTATE, OR OTHER ENTITY

YOUR TITLE

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 0581-0093. The time required to
complete this information collection is estimated to average 30 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.
LPS-1 (rev. 04-17)

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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:
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 202509410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

LPS-1 (rev. 04-17)

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Location of the average number of laying hens entered in response to question 2 on first page of Registration, Ballot, and Certification.
Total of the average number of laying hens at all locations must agree with this figure. If you need additional space, attach another page.
NAME OF FARM AND LOCATION

AVERAGE NUMBER OF LAYING HENS

1.
NAME OF FARM

STREET, RURAL ROUTE, OR R.F.D. NUMBER

COUNTY OR PARISH

CITY OR TOWN, STATE, ZIP CODE
2.
NAME OF FARM

STREET, RURAL ROUTE, OR R.F.D. NUMBER

COUNTY OR PARISH

CITY OR TOWN, STATE, ZIP CODE

3.
NAME OF FARM

STREET, RURAL ROUTE, OR R.F.D. NUMBER

COUNTY OR PARISH

CITY OR TOWN, STATE, ZIP CODE
4.
NAME OF FARM

STREET, RURAL ROUTE, OR R.F.D. NUMBER

COUNTY OR PARISH

CITY OR TOWN, STATE, ZIP CODE

TOTAL
ATTACH ADDITIONAL SHEETS IF NECESSARY
LPS-1 (rev. 04-17)

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