POP-ORB Peanut Official Referendum Ballot

FORM APPROVED OMB NO. 0581-0093
United States Department of Agriculture Agricultural Marketing Service OFFICIAL REFERENDUM BALLOT Popcorn Promotion, Research, and Consumer Information Order		CERTIFICATION _______ During the period of January 1, 20XX and December 31, 20XX, I processed ___________ pounds of popcorn
To be counted, completed ballots must be received by the U.S. Department of Agriculture beginning Month XX, 20XX and no later than Month XX, 20XX, by x:xx p.m. Eastern Standard Time. NOTE: Only one vote will be counted for each eligible first handler and importer. 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 [Amendment (s)] Popcorn Promotion, Research, and Consumer Information program? YES ____ NO ____
PLACE LABEL HERE		III. SIGNATURE ALL BALLOTS MUST BE SIGNED AND DATED BELOW IN ORDER TO BE COUNTED. 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 popcorn, I also CERTIFY that I have the authority to cast this ballot and will submit evidence thereof if so requested by the Referendum Agent. X ____________________________________ ______________________ SIGNATURE DATE _______________________________________ (______)_________-_________ COMPANY NAME BUSINESS TELEPHONE NUMBER
		IV. MAILING Return ballot in the enclosed, postage-paid envelope.

POP-ORB (09/07)

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

U.S. Department of Agriculture, AMS

POPCORN REFERENDUM

P.O. Box XXXXXXX

Washington, D.C xxxxx-xxxx

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)

According to the Paperwork Reduction Act of 1995, an agency may or 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.

POP-ORB (09/07)