POT-ORB Potatoes--Official Referendum Ballot

FORM APPROVED OMB NO. 0581-0093
United States Department of Agriculture Agricultural Marketing Service OFFICIAL REFERENDUM BALLOT POTATO RESEARCH AND PROMOTION PLAN To be counted, completed ballots must be received by the U.S. Department of Agriculture on or after ____ XX, 20XX and before 4:30 p.m. Eastern Standard Time on ___ XX, 20XX.		I. CERTIFICATION _______ I am currently a PRODUCER of potatoes and I handled approximately _________ hundredweight of potatoes between January 1, 20XX and December 31, 20XX. _______ I am currently an IMPORTER of potatoes and I imported _______ hundredweight of potatoes between January 1, 20XX and December 31, 20XX.
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 of the [amendment (s)] Potato Research and Promotion Plan? 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 potatoes, 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.

POT-ORB (09/07)

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

U.S. Department of Agriculture, AMS

POTATO REFERENDUM

XXXXXXX

City, State Zip

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.

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POT-ORB (09/07)