FV-261 Blueberry Referendum Ballot

National Research, Promotion, and Consumer Information Programs

FV-261 (BLU Referendum Ballot)

National Research, Promotion & Consumer Information Programs (Voluntary)

OMB: 0581-0093

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FORM APPROVED OMB NO. 0581-0093

United States Department of Agriculture

Agricultural Marketing Service


OFFICIAL REFERENDUM BALLOT


BLUEBERRY PROMOTION, RESEARCH, AND INFORMATION ORDER


Complete Sections I, II, and II of this ballot. Mail your completed ballot. To be counted, completed ballots must be received by the U.S. Department of Agriculture on ____ XX, 20XX and before 4:30 p.m. Eastern Time.

I. ELIGIBILITY

1. I am currently a cultivated (highbush) blueberry PRODUCER _____ or IMPORTER ______ (Check one), and I paid assessments during the period Month 20XX to Month 20XX.


  1. I produced or imported __________ pounds of blueberries between Month 20XX and Month 20XX.


Preprinted totals for producers include blueberries produced and reported by a producer. Totals for importers include blueberry imports reported by U.S. Customs. If corrections need to be made, please cross out and legibly write in the correct information. Submit documentation to support these changes along with your ballot to USDA.

Note: Only one vote will be counted for each eligible producer and importer. Incomplete ballots may be INVALID and may not be counted in the referendum.


II. VOTE

Instructions: Mark one box only.

Do you favor the continuance of [amendment to] the Blueberry Promotion, Research, and Information Order?

YES NO_____





PLACE LABEL HERE


III. CERTIFICAITON AND SIGNATURE

ALL BALLOTS MUST BE SIGNED AND DATED 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 production or importation of blueberries, I also CERTIFY that I have the authority to cast this ballot.


X ____________________________________ ______________________

SIGNATURE DATE



_______________________________________ (______)_________-_________

COMPANY NAME BUSINESS TELEPHONE NUMBER




IV. MAILING

Return ballot in the enclosed, postage-paid envelope.

FV-261 (rev. 12/13)





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 0581-0093. 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 USDA, Director 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-261 (rev. 12/13)


File Typeapplication/msword
File TitleFORM APPROVED OMB NO
Authorchumphre
Last Modified ByUSDA
File Modified2013-12-30
File Created2013-12-30

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