WAT-ORB Watermelon Official Referendum Ballot

FORM APPROVED OMB NO. 0581-0093

United States Department of Agriculture

Agricultural Marketing Service

OFFICIAL REFERENDUM BALLOT

Watermelon Research and Promotion Plan

Instructions: Mark one box only. Return ballot in the enclosed return-addressed envelope. No postage is necessary. If corrections need to be made to your company or contact name or address, please cross out and legibly write in the correct information. All information gathered will be kept strictly confidential. To be counted, completed ballots must be received at the U.S. Department of Agriculture by x:xx p.m., Eastern Time, Month XX, 20XX.

___ I am currently a PRODUCER of watermelons and I handled ____ acres/pounds between Month XX, 20XX and Month XX, 20XX.

___ I am currently a HANDLER of watermelons and I handled ____ acres/pounds between Month XX, 20xx and Month XX, 20Xx.

___ I am currently an IMPORTER of watermelons and I handled ___ pounds between Month XX, 20xx and Month XX, 20xx.

Do you favor the continuance of the [amendment (s)] Watermelon Research and Promotion Plan?

YES NO

 

I certify 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 handling or importation of watermelons, I also certify that I have the authority to cast this ballot and will submit evidence thereof if so requested by the Referendum Agent.

All ballots must be signed and dated below in order to be counted.

Signature Date

Sample’s Watermelon Co. ____________

Attn: Joe Sample Business phone

701 Lakeside Place

Longwood, FL 32750

County

XXXXXX

FALSIFICATION OF INFORMATION OR MISREPRESENTATION OF IDENTITY ON THIS GOVERNMENT DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN $10,000, OR IMPRISONMENT FOR NOT MORE THAN FIVE YEARS OR BOTH (18 U.S.C. 1001).

WAT-ORB (09/07)

According to the Paperwork Reduction Act of 1995, an agency may or may not conduct a 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 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.

WAT-ORB (09/07)