FV-258 Peanut Official Referendum Ballot

FORM APPROVED

United States Department of Agriculture
Agricultural Marketing Service
OFFICIAL REFERENDUM BALLOT
Peanut Promotion, Research, and
Information Order

OMB NO. 0581-0093

I. CERTIFICATION
1. I paid assessments under the National Peanut Board Check-off during
the period ITomMonth xx, 20xx to Month xx, 20xx.

NOD

YES D

To be counted, completed ballots must be received by the
U.S. Department of Agriculture on Month _,20_, by
x:xx p.m., Eastern Daylight Saving Time.

NOTE: Only one vote will be counted for each eligible
producer. Incomplete ballots will be INVALID and
will not be counted in the referendum.

II. VOTE
Instructions: Mark one box only.

Do you favor the continuance of the National
Peanut Board Check-off implemented under the
Peanut Promotion, Research, and Information
Order?

YES D

NOD

III. MAILING
FV-258

Return ballot in the enclosed postage-paid envelope.

If postage-paid envelope is not available, mail your ballot(s) to:

u.s. Department of Agriculture, AMS
PEANUT REFERENDUM
P.O. Box xxxxxx
Washington, D.C xxxxx-xxxx
F ALSIFICA TION OF INFORMA nON OR MISREPRESENTATION OF IDENTITY ON THIS GOVERNMENT
IMPRISONMENT FOR NOT MORE THAN FIVE YEARS, OR BOTH. (18 U.S.c. 1001)

DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN $10,000, OR

According to the Paperwork Reduction Act of 1995, an agency mayor 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 the information collection is 0581-0093. The time
required to complete this information collection is estimated to average 15 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). To file a complaint of discrimination, write USDA, Director 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.

OMB#0581-0093

ALL BALLOTS MUST BE SIGNED BELOW IN ORDER TO BE COUNTED.

I CERTIFY that I am the person authorized to cast this ballot and 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. If this ballot is being cast on behalf of any group of individuals, partnership, corporation, or other business entity engaged in the production of peanuts, I also
CERTIFY that I have the authority to cast this ballot.

SIGNATURE

DATE
(}

COMPANY NAME

-

BUSINESS TELEPHONE NUMBER

According to the Paperwork Reduction Act of 1995, an agency mayor 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 the information collection is 0581-0093. The time required to complete this information collection is estimated to average 15 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). To file a complaint of
discrimination, write USDA, Director of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TOD). USDA is an equal opportunity provider and
employer.

[This will be on the envelop sent to peanut producers to sign as part of the ballot]

FV -258 Reverse

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