Concrete Masonry Products Research, Education, and Promo

OMB Control No. 0605-0029

Expiration Date: XX/XX/XXXX

United States Department of Commerce Under Secretary for Economic Affairs OFFICIAL REFERENDUM BALLOT Concrete Masonry Promotion, Research, and Education Order Complete Sections I, II, and III of this ballot. To be counted, completed ballots must be postmarked by XX-XX, 202X. Ballots delivered via express mail must show proof of delivery by no later than 11:59 p.m. Eastern Time on XX-XX, 202X. NOTE: Only one vote will be counted for each eligible concrete masonry manufacturer. Incomplete ballots may be INVALID and may not be counted in the referendum. «USDOC CMP 0001» «Manufacturer Name» «Address»	I. ELIGIBILITY Please check where applicable. □ I am a Manufacturer of Concrete Masonry Units (CMU) and have manufactured CMUs within the last 180 days. Employer Identification Number (EIN) ________________ The number of concrete masonry unit machine cavities I have in operation under this EIN: ________________
	II. VOTE Instructions: Mark one box only. Do you favor the implementation of the Concrete Masonry Products Research, Education, and Promotion Order? For more information and to review the order go to concrete checkoff@doc.gov. YES □ NO □
	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. 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 NUMBER EMAIL ADDRESS
	IV. MAILING Fax ballot to (301) 278-xxxx or return in the enclosed, postage-paid envelope.

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

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. This is a new collection and the valid OMB Control Number will be assigned when it is approved. The time required to complete this information is estimated to average 25 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. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Department of Commerce, Office of the Under Secretary for Economic Affairs at 1401 Constitution Avenue, Washington, D.C. 20230, Attn: Kenneth White, Senior Policy Analyst, or kwhite2@doc.gov.

Privacy Act Statement

All information collected will be treated as confidential, as indicated on the forms and in conformance with the Privacy Act and Freedom of Information Act. The Department’s staff is required to maintain confidentiality. Other confidential information will be withheld from public review under the Freedom of Information Act and the Privacy Act, 5 USC 552.