Form LS-49 Soybeans- Referendum Ballot

National Research, Promotion, and Consumer Information Programs

LS-49 Referendum Ballot

National Research, Promotion & Consumer Information Programs (Voluntary)

OMB: 0581-0093

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FORM APPROVED - OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

REFERENDUM ON THE SOYBEAN PROMOTION
AND RESEARCH ORDER BALLOT
NOTE: INSTRUCTIONS TO VOTERS (Please read carefully)
1. If voting as an individual, you must vote in the county Farm Service Agency (FSA) Office in the county in which you reside, or the county FSA Office
serving the county in which you reside.
2. If voting on behalf of an entity (partnership, corporation, estate, etc.) you must vote in the county FSA office in which it is located, or the county FSA office
serving the county in which it is located.
3. Complete all sections.

Section A
Do you support continuation of the Soybean Promotion and Research Order?

Yes

No

Section B: Name and Address
Name of person or Other Entity Represented: (Print)

Address: (Street, P.O. Box, or Route No.)

City:

State:

Zip Code:

Section C: Certification Statement and Signature
I HEREBY CERTIFY that I am a person (any individual, group of individuals, partnership, corporation, association, cooperative
or any other legal entity) or authorized representative and have engaged in the production of soybeans from:
to
I am voting only once in the same capacity registered.
I FURTHER CERTIFY that the supporting documentation that I am providing along with this form is true, complete, and correct.
FAILURE TO PROVIDE supporting documentation showing that the person voting was engaged in the production of soybeans as
indicated above, complete the ballot in its entirety, or provide a signature will invalidate this ballot.

Signature

Title

Date

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 6 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.
LS-49


File Typeapplication/pdf
File TitleMicrosoft Word - Revised LS-49
AuthorLGallion
File Modified2007-08-08
File Created2007-08-08

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