No Form number (987) 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

(Rev. 01/2017) Destroy previous editions.