No Form number CA Date Ballot (Voter Eligibility)

OMS No. 0581-0178

CERTIFICATION

OF VOTER ELIGIBILITY

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE NOMINATIONS
VOTER ELIGIBILITY: Producers who delivered dates to handlers in the current marketing year shall be
eligible to vote for producer nominees unless such producers also have a proprietary interest in a date
packing facility, as explained in the attached voting guidelines.
Please provide the following information. The ballot will be invalidated if this certification is not completed.
, of

I,

do hereby certify that I am a producer of Deglet Noor, Halawy, Khadrawy,
or Zahidi dates and that I am qualified to vote for producer representatives to serve on the California Date
Administrative Committee. I also certify that I have no proprietary interest in a date packing facility. (For
the purpose of this ballot, ownership of stock in a date packing facility does not preclude an individual from
voting as a producer, unless ownership of such stock allows the stockholder to dictate policy in the
operation and management of said packing facility.)
I further certify that I have voted on the attached ballot as ONE of the following:
( ) Owner-operator

( ) Partnership (Name:
Partners:

)
)

( ) Cash rent tenant

)
)

( ) Share tenant

( ) Corporation (Name:
Date of Incorporation:
( ) Estate (Name:

( ) Share landlord

( ) Trust (Name:

)

)

)

( ) Other (Specify:
Name(s) of handler(s) to whom I have delivered dates this marketing year (October 1,
through April 3D,
):

Signature:

Date:

Telephone Number:!
Title (if Corporation, Estate, or Trust):
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 OMS control number. The valid OMS control number for this information collection is 0581-0178. The time required
to complete this information collection is estimated to average 5 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.)
Personswith 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, SW., Washington, D.C. 20250-9410, or
call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
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