Form HWL-ORB Official Referendum Ballot

FORM APPROVED OMB NO. 0581-NEW

United States Department of Agriculture Agricultural Marketing Service OFFICIAL REFERENDUM BALLOT Hardwood Lumber and Hardwood Plywood Promotion, Research, and Information Order To be counted, completed ballots must be received by the U.S. Department of Agriculture on Month XX, 20xx, by 4:30 p.m. Eastern Time. NOTE: Only one vote will be counted for each eligible hardwood lumber or hardwood plywood manufacturer. Incomplete ballots may be INVALID and may not be counted in the referendum.	I. ELIGIBLITY I Manufactured and Shipped within the United States ______________ (volume and/or value) of hardwood lumber and hardwood plywood during the period Month XX through Month XX, 20xx, and I am an eligible hardwood lumber and hardwood plywood manufacturer. **USDA may request documentation to support the above statement.
	II. VOTE Instructions: Mark one box only. Do you favor implementing the Hardwood Lumber and Hardwood Plywood Promotion, Research, and Information Order? YES  NO 
	III. CERTIFICATION AND SIGNATURE ALL BALLOTS MUST BE SIGNED BELOW IN ORDER TO BE COUNTED. I CERTIFY that I am the person authorized to cast this ballot and 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 manufacture of covered hardwood lumber, I also CERTIFY that I have the authority to cast this ballot. X ______________________________ _____________ SIGNATURE DATE ________________________________ ENTITY NAME BUSINESS TELEPHONE NUMBER
	IV. MAILING Return ballot in the enclosed, postage-paid envelope.

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-NEW. 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 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.

HWL-ORB (06/12)