FV-72 Dates Producer Referendum Ballot

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0178

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAM

PRODUCER REFERENDUM BALLOT

MARKETING ORDER NO. 987

On the proposed amendment of Marketing Order No. 987, as amended, for domestic dates produced or packed in Riverside County, California. This Ballot will be held confidential. Please read the enclosed rules of eligibility and voting instructions before completing this Ballot. Your Ballot envelope MUST be received by this office not later than ___________________, 20___, in order to be counted in this referendum.

I HEREBY CERTIFY that I am, or the producer’s name I have inserted in Item 4 below is, now an eligible producer of Deglet Noor, Zahidi, Khadraw or Halawy dates, and that during the period from October 1, 20___, through September 30, 20___, produced the following quantity of dates for market:

_________________________ pounds (Field run)

NOTE: If you are farming on a share crop basis, report only that part of the tonnage representing your share.

1. Name(s) of any partners

2. Partner(s) mailing address

3. Do you favor the proposed amendment? □ Yes □ No

4. Producer’s Signature (or name, if Item 6 is applicable)

5. Mailing Address (Street and No., RDF No., City, State, Zip Code)

6. If this Ballot is cast by an officer or employee of a corporate producer, such as a corporation, institution, or school, or by an administrator, executor, or trustee of a producing estate, the following must also be completed.

I HEREBY CERTIFY to the Secretary of Agriculture (Secretary) that I have authority to case this Ballot for the producer named above in Item 4 and that I will submit evidence of such authority at the request of the Agency of the Secretary.

Signature:

Title or Capacity:

Mailing Address:

Your signature certifies that you have the authority to take such action and will submit supplementary evidence of such authority at the request of the Agent of the Secretary. The information in this Ballot is required to determine the voter eligibility and vote of date producers. Falsification of information on this government document may result in a fine or imprisonment, or both (18 U.S.C. 1001).

Final Decision – Dates

The undersigned hereby authorizes the Deputy Administrator, or the Acting Deputy Administrator, Fruit and Vegetable Programs, Agricultural Marketing Service, U.S. Department of Agriculture, to correct any typographical efforts which may have been made in this marketing agreement.

IN WITNESS WHEREOF, the contracting parties, acting under the provisions of the Agricultural Marketing Agreement Act, for the purpose and subject to the limitations therein contained, and not otherwise, have hereto set their respective signatures and seals.

________________________________________ By: _______________________________________________

Firm Name Signature¹

________________________________________ __________________________________________________

Mailing address Title

__________________________________________________

Date of Execution

Corporate Seal:

if none, so state

¹ If one of the parties to the marketing agreement is a corporation, my signature constitutes certification that I have the power granted to me by the Board of Directors to bind this corporation to the marketing agreement.

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 0581-0178. The time required to complete this information collection is estimated to average 20 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 of 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, political beliefs, genetic information, 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.

FV-72 (Rev. 01/2014) Destroy previous editions.