LPS-51-1 Soybean Request for Referendum

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

FORM APPROVED. – OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SOYBEAN PROMOTION AND RESEARCH 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 0581-0093. The time required to complete this
information collection is estimated to average 6 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
CERTIFICATION
STATEMENT
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. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

I HEREBY CERTIFY that I am a soybean producer or producer entity that I am authorized to represent and have paid an assessment
sometime during
, through
. 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 soybean
assessment was paid and complete and sign this form will invalidate the request.
NAME OF INDIVIDUAL PRODUCER OR OTHER PRODUCER ENTITY (Print)

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

TELEPHONE NUMBER (Including Area Code)

COUNTY

IMPORTANT: Sign and date this form if you wish to request a referendum on the Soybean Promotion and Research
Order.
SIGNATURE OF PRODUCER OR REPRESENTATIVE OF PRODUCER ENTITY

TITLE (If applicable)

LPS-51-1 (Rev. 04/17)

DATE