Form POT-ORB Potatoes--Official Referendum Ballot

APPROVED - OMB NO. 0581-0093
United States Department of Agriculture Agricultural Marketing Service OFFICIAL REFERENDUM BALLOT POTATO RESEARCH AND PROMOTION PLAN To be counted, completed ballots must be received by the U.S. Department of Agriculture on XX, 20XX, by X:XX p.m. Eastern Time.		I. ELIGIBILITY _______ I am currently a PRODUCER of potatoes and I produced approximately _________ hundredweight of potatoes between January 1, 20XX, and December 31, 20XX. _______ I am currently an IMPORTER of potatoes and I imported _______ hundredweight of potatoes between January 1, 20XX, and December 31, 20XX.
NOTE: Only one vote will be counted for each eligible producer and importer. Incomplete ballots may be INVALID and may not be counted in the referendum.		II. VOTE Instructions: Mark one box only. Do you favor the continuance of the [amendment (s)] Potato Research and Promotion Plan? YES NO ______
PLACE LABEL HERE		III. CERTIFICATION AND SIGNATURE ALL BALLOTS MUST BE SIGNED BELOW IN ORDER TO BE COUNTED. I CERTIFY that the information contained on this ballot is true, complete, and correct to the best of my knowledge and belief, and is made in good faith. If this ballot is being cast on behalf of any group of individuals, partnership, corporation, or other business entity engaged in the producing or importation of potatoes, I also CERTIFY that I have the authority to cast this ballot and will submit evidence thereof if so requested by the Referendum Agent. X ____________________________________ ______________________ SIGNATURE DATE _______________________________________ (______)_________-_________ COMPANY NAME BUSINESS TELEPHONE NO.
		IV. MAILING Return ballot in the enclosed, postage-paid envelope.

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If postage-paid envelope is not available, mail your ballot(s) to:

U.S. Department of Agriculture, AMS

POTATO REFERENDUM

Street

City, State, Zip

The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, §1001 United States Code, which provides for the penalty of a fine of $10,000, imprisonment of not more than 5 years, or both.

According to the Paperwork Reduction Act of 1995, an agency may or 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 the information collection is 0581-0093. 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: 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.

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