PY-1 Egg Research & Promotion Registration, Ballot, and Certi

FORM APPROVED – OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE EGG RESEARCH AND PROMOTION ORDER REGISTRATION, BALLOT, AND CERTIFICATION

INSTRUCTIONS: Please complete all information and forward in the enclosed envelope to the Referendum Agent, Poultry Programs, Agricultural Marketing Service, USDA, 1400 Independence Ave., SW., Stop 0256, Washington, DC 20250-0259. Mark an “X” in appropriate blocks. Completed ballots must be postmarked not later than __________________. Incomplete ballots or ballots received after ________________ will be invalid and will not be counted for any purpose in the referendum. The information you provide below regarding the number of laying hens, location, egg production figure, and how you voted shall be kept confidential.

REGISTRATION

__________________________________________ __________________________________________

NAME OF EGG PRODUCER (Print or type) STREET, RURAL ROUTE, OR R.F.D. NUMBER

(If corporation, partnership, estate, etc., list name of business entity. If

Individually owned, list last name first, first name, and middle initial of sole

Proprietor.) _______________________________________________________________

COUNTY OR PARISH

_______________________________________________________________

CITY OR TOWN, STATE, ZIP CODE

1. At any time during the period ____________________ through ____________________ did you

o

wn over ________ laying hens, excluding hens primarily engaged in the production of hatching eggs?... YES NO

2. State average number of laying hens owned during the period ____________________ through

____________________. List location of such laying hens on the reverse side of this form……

3. S

   
   

   tate total number of 30-dozen cases of eggs produced by laying hens during the period

____________________ through ____________________.......................................................

NOTE: If you do not have a record of the number of cases of eggs produced, use the following computation which is based on the national average: Multiply average number of laying hens owned times a factor of 0.174.

E XAMPLE; 300,000 laying hens x 0.174 = 52,200 cases

BALLOT

Do you favor ________________________________________________________________________

_

__________________________________________________________________________________. YES NO

CERTIFICATION STATEMENT

I hereby certify that I am an egg producer as defined in the order, that during the period ____________________ through ____________________ , I was an egg producer as defined in the order, and that the information contained in this Registration,

Ballot, and Certification is true, complete, and correct to the best of my knowledge and belief and is made in good faith.

______________________________________ ____________________________________ ____________________

NAME (Print or type) SIGNATURE* DATE

*If the vote is cast on behalf of a corporation, estate, or any person other than an individual, my signature certifies that I have the authority to take such action. In such case, provide the following information:

_____________________________________________ ________________________________

NAME OF CORPORATION, PARTNERSHIP, ESTATE, OR OTHER ENTITY YOUR TITLE

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 OMB control number. The valid OMB control number for this information collection is 0581-0093. The time required to complete this information collection is estimated to average 30 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 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 (TDD). USDA is an equal opportunity provider and employer.

PY-1 (08-07) (OVER)

L ocation of the average number of laying hens entered in response to question 2 on first page of Registration, Ballot, and Certification. Total of the average number of laying hens at all locations must agree with this figure. If you need additional space, attach another page.

NAME OF FARM AND LOCATION			AVERAGE NUMBER OF LAYING HENS
1.
NAME OF FARM
STREET, RURAL ROUTE, OR R.F.D. NUMBER
COUNTY OR PARISH
CITY OR TOWN, STATE, ZIP CODE
2.
NAME OF FARM
STREET, RURAL ROUTE, OR R.F.D. NUMBER
COUNTY OR PARISH
CITY OR TOWN, STATE, ZIP CODE
3.
NAME OF FARM
STREET, RURAL ROUTE, OR R.F.D. NUMBER
COUNTY OR PARISH
CITY OR TOWN, STATE, ZIP CODE
4.
NAME OF FARM
STREET, RURAL ROUTE, OR R.F.D. NUMBER
COUNTY OR PARISH
CITY OR TOWN, STATE, ZIP CODE
	TOTAL

ATTACH ADDITIONAL SHEETS IF NECESSARY

PY-1 (REVERSE)