Form CN-100 Cotton Referendum Ballot & Ballot envelope

United States
Department of
Agriculture

Agricultural
Marketing
Service

1400 Independence Avenue, SW.
Washington, D.C. 20250

Form Approved
OMB No. 0581-0093
To request a continuance referendum, please complete the attached form and return it to [Insert
USDA Farm Service Agency Address]. For your signature to be counted during the sign-up
period, your request must be received no later than [insert date]. No action is necessary if a
continuance referendum is not desired.

I,

request that the U.S. Department of

(PRINT FULL NAME)
Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton
Research and Promotion Order.

Print Name

Address

Date

Signature

Company Name
BURDEN AND NONDISCRIMINATION

STATEMENTS

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 05810093. 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national
origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information,
political belieft, reprisal, or because all or part of an individual's income is derived from any public assistance program (not all prohibited bases
apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print,
audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). Tofile a complaint of discrimination, write to
USDA. Director, Office of Civil Rights, 1400 Independence Avenue, S. w., Washington. D.C. 20250-9410. or call (800) 795-3272 (voice) or (202)
720-6382 (TDD). USDA is an equal opportunity provider and employer.
CN-I00. Attachment A

Notice XX-XXXX
Notice XX-XXXX
In-Office Sign-UpSheet
County FSA Sign-UpSheet
Date

Print Name

Sie:nature

Exhibit 2
Page

of
Remarks

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BURDEN AND NONDISCRIMINATION STATEMENTS

Form Approved OMB NO. 0581-0093

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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance
program (not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication
of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and
TDD). Tofile a complaint of discrimination,write to USDA,Director, Office of CivilRights, 1400 Independence
Avenue.S.w.,
Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and
employer.
CN-JOO, Attachment B

United States
Department of
Agriculture

Agricultural
Marketing
Service

1400 Independence Avenue, SW.
Washington, D.C. 20250

Form Approved
OMB No. 0581-0093
To request a continuance referendum, please complete the attached form and include a copy of at
least one sales receipt and return these documents to the County FSA office where your farm is
located. For your signature to be counted during the sign-up period your request must be
received not later than (Insert Date). No action is necessary if a continuance referendum is not
desired.

I,

request that the U.S. Department of

(PRINT FULL NAME)
Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton
Research and Promotion Order.

Print Name

Address

Date

Signature

Company Name
BURDEN AND NONDISCRIMINATION

STATEMENTS

According to the Paperwork Reduction Act of i 995, 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 058i0093. The time required to complete this i1iformation collection is estimated to average 6 minutes per response, including the timefor reviewing
instructions. searching existing data sources. gathering and maintaining the data needed. and completing and reviewing the collection of
information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national
origin, age. disability. and where applicable, sex, marital status. familial status, parental status, religion, sexual orientation, genetic information.
political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program (not all prohibited bases
apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print,
audiotape, etc.) should contact USDA 's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to
USDA. Director, Office of Civil Rights, 1400 independence Avenue, S. w., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202)
720-6382 (TDD). USDA is an equal opportunity provider and employer.

CN-100.Allachment C

United States
Department of
Agriculture

Agricultural
Marketing
Service

1400 Independence Avenue, SW.
Washington, D.C. 20250

Form Approved
OMB No. 0581-0093

To request a continuance referendum, please complete the attached form and include a copy of one
U.S. Customs and Border Protection Form 7501 showing payment of a cotton assessment for
calendar year 2001 and return these documents to [Insert USDA Farm Service Agency Address].
For your signature to be counted during the sign-up period your request must be received not later
than (Insert Date). No action is necessary if a continuance referendum is not desired.

I,

request that the U.S. Departmentof
(PRINT FULL NAME)

Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton
Research and Promotion Order.

Print Name

Signature

Date

Company Name

BURDEN AND NONDISCRIMINATION STATEMENTS
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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age,
disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs,
reprisal, or because all or part of an individual's income is derivedfrom any public assistance program (not all prohibited bases apply to all
programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.)
should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). Tofile a complaint of discrimination, write to USDA, Director, Office of
Civil Rights, 1400 Independence Avenue, S. W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an
equal opportunity provider and employer.

CN-IOO,AttachmentD