Form LP-4 Nomination for Appointment

OMB No. 0581-NEW

NOMINATION FOR APPOINTMENT TO THE NATURAL GRASS SOD BOARD
NATURAL GRASS SOD PROMOTION, RESEARCH, AND INFORMATION ORDER (7 CFR 1240)
Note: 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 5 years, or both.
The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. §522a) and the Paperwork Reduction Act of 1995, as amended. The authority for
requesting this information to be supplied on this form is from the applicable commodity legislation for research and promotion programs. Furnishing the requested
information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or other unique identification number is mandatory and
will be used to determine affiliation or entity identity.

Nominees must meet eligibility requirements as described in §§1240.XX and 1240.XX of the Order. Nominees
must produce and sell Natural Grass Sod Products in the Region for which they seek nomination and may be asked
to provide substantiating documentation to the Board. Nominees that produce and sell Natural Grass Sod Products in
multiple regions may seek nomination in one region of their choice. As set forth in §1240.XX of the Order, the
regions are as follows: North/Cool-Season Region, South/Warm-Season Region, and Transition Zone/
California Region.
Name of Nominee and Region for which person is nominated:
Nominee Name:
Region*:
Farm/Company Name:
Address:
City:

State:

Zip:

*North/Cool-Season Region includes the following States: Alaska, Colorado, Connecticut, Delaware, Idaho, Illinois, Indiana, Iowa, Maine,
Massachusetts, Michigan, Minnesota, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode
Island, South Dakota, Utah, Vermont, Washington, Wisconsin, and Wyoming.
South/Warm-Season Region includes the following States: Alabama, Arizona, Florida, Georgia, Hawaii, Louisiana, Mississippi, Nevada, New
Mexico, South Carolina, Texas, and all territories and possessions of the United States, including but not limited to, the Commonwealth of Puerto Rico.
Transition Zone/California Region includes the following States: Arkansas, California, the District of Columbia, Kansas, Kentucky, Maryland,
Missouri, North Carolina, Oklahoma, Tennessee, Virginia, and West Virginia.

Nomination is being submitted on behalf of:
□ Natural Grass Sod Producer
Name:
Farm/Company Name:
□ Industry Organization with a board comprised of a majority of Natural Grass Sod Producers
Organization Name:
Address:
City:

State:

Phone No.:

Email:

LP-4 (Expiration Date XX/XX/XXXX)

Zip:

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Person Completing this Nomination Form:

Name:

Title:

□ If nomination is being submitted on behalf of an industry organization, I hereby certify that the board of such
industry organization is comprised of a majority of Natural Grass Sod Producers. (check box if applicable)
Signature:

Return Original Forms to:

Date:

Natural Grass Sod Board
Address
County, State Zip
Or Email

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-NEW. 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.
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.

LP-4 (Expiration Date XX/XX/XXXX)

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