No Form number CA Date--Certificate of Voter Eligibility

OMB No. 0581-0178

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

CERTIFICATE OF VOTER ELIGIBILITY

VOTER ELIGIBILITY: Producers who delivered dates to handlers in the current marketing year shall be eligible to vote for producer nominees unless such producers also have a proprietary interest in a date packing facility, as explained in the attached voting guidelines.

Please provide the following information. The Ballot will be invalidated if this certification is not completed.

I, __________________________________, of ______________________________________________________

Print Name Address

do hereby certify that I am a producer of Deglet Noor, Halawy, Khadrawy, or Zahidi dates and that I am qualified to vote for producer representatives to serve on the California Date Administrative Committee (Committee). I also certify that I have no proprietary interest in a date packing facility. (For purpose of this Ballot, ownership of stock in a date packing facility does not preclude an individual from voting as a producer, unless ownership of such stock allows the stockholder to dictate policy in the operation and management of said packing facility.)

I further certify that I have voted on the attached Ballot as one of the following:

□ Owner-operator □ Partnership – Name: ______________________________________________

Partners: _________________________________________________________

□ Cash rent tenant □ Corporation – Name: _____________________________________________

Date of Incorporation: ______________________________________________

□ Share tenant □ Estate – Name: __________________________________________________

□ Share landlord □ Trust – Name: ___________________________________________________

□ Other – Specify: ______________________________________________________________________________

Name(s) of handler(s) to whom I have delivered dates this marketing year (October 1, 20___ through April 30, 20___): ________________________________________________________________________________

Signature: _______________________________________ Date: ______________________________________

Title: ___________________________________________ Phone No.: _________________________________

Title (if Corporation, Estate or Trust): ______________________________________________________________

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 5 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.

(Rev. 01/2014) Destroy previous editions.