FV-110 Producer Referendum (Southeastern Potatoes)

FORII APPROVED

REPRODUCE LOCALLY. Include form number and date on aU reproductions.

. 0118 NO.OSI1.o178

UNITED STATES DEPARTMENT 01' AGRlCVL11JRE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

CONTINUANCEREFERENDUM
OFFICIAL BALLOT
MARKETING ORDER NO..953
IRISH POTATOES GROWN IN SOUTHEASTERN STATES
PART 1- REFERENDUMINSTRUcnONS
A.

.COMPLETE PARTS n, In, AND IV. Incompleteor unsignedballotscannotbe counted. BaOotsmust be postmarked by

B.

EUGIBILITY REQUIREMENTS: Anypersonwhoproducedpotatoesfor'1teshmarketduringthe period
~

through

and who is now a producer, is eligible 10vote. Such persons may vote on whether they &vOlcontinuance of the order

by using the enclosed ballot. Additional baUots may be obtained by contacting the
or yom' C01DltyExtension Service office.

1.

A producer (or grower) is defined as: (a) any person who producespotatoes for fresh

~

production areal

); (b) aremerortenant,of

in the designated

acreage producing potatoes for 1teshJI181tet;or (c) a 1and1ordwho received fi"oma renter or tenant such potatoes as rent
for the land on which such potatoes were grown. A cash landlord, lienholder, or perSon having only a financial interest
in the crop is not an eligible voter.

c.

2.

A businessunit,partnership,fiunilyenterprise,corporation,association,estate,or firmmay vote. Eachsuchentity is
entitledto onevote.

3.

Proxyvotingis not authorized.

INSTRUCTIONS FOR VOTING: Provide the voter informationrequested in Part n. In Part m. mark the block for or against
continumgthe order. Certii)ryom' vote by signing the appropriate section of Part IV. If you do not complete Parts n, ill, and IV,
yom' ballot cannot be validated, and yom' vote will not be counted.

Removethe pagescontainingPartsII, ill, and IV. andmailthemin the self-addressedenvelope. If you do not have an official
envelope.sendthe ballotto the USDA's

MarketingFieldOffice.

. Mark the envelope "POTATO
Pleasecall

FV-110 (06/04)

REFERENDUM".

if you have any questions.

Page 1 of 3

PART 0

-VOTER INFORMATION

This information will be beld in s1rictconfidence.

A.

YOm'name
(please print clearly)

B.

What is the specificlocationof YOm'potato acreagerepresentedin this ballot?

(Highway or street address, if applicable. and county)

(City. State. and ZIP Code)

C.

DOyou resideonthe abovepropertywhicbproducesthe potatoes? (
addressandtelephonenumber:

) Yes

(

) No If no. pleaseprovideyourresidence

(Street and No. or R.F.D. No.. City. State. and ZIP Code)

(Telephone number (Area Code»
D.

If you are not voting as an individual producer. please check the appropriate box indicating your voting status and write the

name andaddressof the businessunit you represent.
(

) Partnership

(

) Corporation

(

.

) Other (Specify)

(Name and address of business unit)

E.

How many hundredweight of potatoes did you produce for itesh market during the period
bundredweight

F.

How many acres of potatoes for ftesb market did you harvest during the period
acres

G.

Which packing house(s) handled your potatoes during the period

?

?

?

(Name ofpacldng house(s»

FV-110 (06/04)

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PART m - CONTINUATION OF MARKETING ORDER FOR POTATOES
Do you favor continuiDathe marbtiDa order for potatoes grownInVA-NC? (

) YES (

) NO

PART IV - VOTER CERTD'ICATION
All iDfonDadODprovided In this ballot will be subject to on-site verification bY ofttcials of the 0ft1ce of Inspector General, U.S.
DepartmoIIt of Agriculture.'
.
The iDfcmDationon this ballot is required to determine voter elf&ibilltyuuI vo1e of southeastem potato producers. Fa1sifi~
of
information on this govOl'DlDODt
document may result In a fiDeofnot more dum S10.000 or impriscmmeat for not more dum fiw (5)
yean. or bo1h (18 U.S.C. 1001).
A.

YOm'signature. if signiDs u an individual.
1 am the producer named In Part n of this ballot. uull certitY that I am DOta cash 1andlord. Heuholder. or person having only
a fiDancial interest In the crop. iDd that the information provided on this ballot uuI any attachment hereto is accurate uuI
correct to the best ofmy knowledge.

,
(signature)
B.

(Date)

If signing u the representative of a producing entity other dum an individual. designate YOID'
title uuI sign below.
I hereby certi1Ythat 1have authority to cast the ballot of the producer named in Part D D of this ballot. ~d that 1wiD submit
evidence thCfCOfat the request of an autho~
agent of the Secretary of Agriculture.

(S~

and title)

BALLOTS POSTMARKED AFrER
REFERENDUM.

(Date)

. WILL.Bm: BE COUNTED IN THE

According to the Paperwork Reduction Act of 1995, an agency may not conduct or Jponror, and a perron is not required to reJpond to
a collection of information unleJJ it diJplayJ a valid OMB control number. The valid OMB control number for thlJ information
collection IJ 0581-0178. The time required to complete thlJ information collection iJ estimated to average 20 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, sa, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisa~ 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 (Bratlle, 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 (/DD). USDA is an equal opportunity provider and
employer.

FV-110 (06/04) (Destroy previous ealtlons)

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