Form DA-21-R Fluid Milk Promotion Order Continuance Referendum (Proce

OFFICIAL REFERENDUM BALLOT:

OMB NO. 0581-0093

United States Department of Agriculture
Agricultural Marketing Service
Dairy Programs
FLUID MILK PROMOTION ORDER CONTINUANCE REFERENDUM
FLUID MILK PROCESSORS

FLUID MILK PROMOTION ORDER

See the reverse of this form for instructions for completing the ballot. This ballot and the information provided will
be kept confidential. (Please type or print.)

___________________________________________________________
Processor Name
___________________________________________________________
Processor Address
________________________________________
City

_________
State

____________________
Zip Code

_____________________________________________________________________________________________
BALLOT: DO YOU FAVOR CONTINUATION OF THE FLUID MILK PROMOTION ORDER?
(Place an “X” in only one space)

□ YES, continue the Order
□ NO, terminate the Order
_____________________________________________________________________________________________

I hereby CERTIFY that the name and address above are correct and that I am eligible to vote as set forth on the
reverse side of this ballot. My signature below certifies that I have the authority to act on behalf of this organization.

____________________________________
Name (Please Type or Print)

_____________________________________
Signature

____________________________________
Title

_____________________________________
Date

FALSIFICATION OF INFORMATION ON THIS GOVERNMENT DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN
$10,000 OR IMPRISONMENT FOR NOT MORE THAN 5 YEARS, OR BOTH (18 U.S.C. 1001)
(over)
Form DA-21-R (08/07)

(FRONT PAGE)

OFFICIAL REFERENDUM BALLOT Instructions

OMB NO. 0581-0093

Fluid Milk Promotion Order Continuance Referendum
The Fluid Milk Promotion Act of 1990 (Title XIX, subtitle H, of the Food, and Agriculture, Conservation, and Trade Act of
1990, Pub L. 1001-624) authorized the establishment of a national program for fluid milk promotion. This program is funded by
a 20-cent per hundredweight assessment on fluid milk products processed and marketed commercially in consumer-type
packages in the 48 contiguous United States and the District of Columbia by fluid milk processors, excluding deliveries directly
to the residence of consumers. A board of 20 members, 15 who represent geographic regions and five at-large members, has
been appointed by the Secretary of Agriculture to administer the Order.
The Act requires the Secretary to conduct a continuation referendum among fluid milk processors to determine if they approve
the continuation or termination of the Fluid Milk Promotion Order. Continuation of the Order is contingent upon approval by at
least 50 percent of the fluid milk processors voting. Those voting for approval also must have processed and marketed
collectively 60 percent or more of the fluid milk products marketed in the United States by processors participating in the
referendum.
I. Referendum Period. Voting will be conducted by mail beginning __________________ through _______________.
Ballots postmarked after _______________ will not be counted.
II. Processors Eligible to Vote Must Meet ALL of the Following Conditions:
1. Be registered by _____________.
2. Have processed and marketed commercially at least 3,000,000 pounds of fluid milk products in consumer-type packages in
the United States during _____________ excluding deliveries directly to the residence of consumers.
3. Be processing and marketing fluid milk products in consumer-type packages in the United States:
a. At the time of voter registration, and
b. At the time of voting.
III. Instructions for Completing the Ballot.
1. Vote in the space provided.
2. Type or print your name and title, sign, and date the ballot.
3. Correct the printed mailing address, if necessary.
4. Mail the ballot in the pre-addressed envelope so that it is postmarked during the period of ________ through ___________.
If you do not have a pre-addressed envelope, mail the ballot to:
Referendum Agent
USDA, AMS, Dairy Programs
Room 2968-S, Mail Stop 0225
1400 Independence Avenue SW
Washington, D.C. 20250-0225
If you have questions or need information on the referendum, call the Referendum Agent at (202) 720-6909.
According to the Paperwork Reduction Act of 1995, an agency my 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.
Form DA-21-R (08/07)

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