LS-51-1 Soybean Request for Referendum

REPRODUCE LOCALLY. Include form number and date on all reproductions.

FORM APPROVED – OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

SOYBEAN PROMOTION AND RESEARCH ORDER
REQUEST FOR REFERENDUM

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.

CERTIFICATION STATEMENT
I HEREBY CERTIFY that I am a soybean producer or producer entity that I am authorized to represent and have paid an assessment
sometime during
, through
. I am requesting a referendum 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 to the best of my knowledge and belief. Failure to provide supporting documentation showing that a soybean
assessment was paid and complete and sign this form will invalidate the request.
NAME OF INDIVIDUAL PRODUCER OR OTHER PRODUCER ENTITY (Print)

ADDRESS (Street, P.O. Box, or Route No., City, State, ZIP Code)

TELEPHONE NUMBER (Including Area Code)

COUNTY

IMPORTANT: Sign and date this form if you wish to request a referendum on the Soybean Promotion and Research
Order.
SIGNATURE OF PRODUCER OR REPRESENTATIVE OF PRODUCER ENTITY

TITLE (If applicable)

LS-51-1

DATE