SWL-ORB Softwood Lumber---Referendum Ballot

FORM APPROVED OMB NO. 0581-0093

I. ELIGIBLITY

United States Department of Agriculture
Agricultural Marketing Service
OFFICIAL REFERENDUM BALLOT
Softwood Lumber Research, Promotion, Consumer
Education and Industry Information Order

I Manufactured and Shipped within the United States or Imported to
the United States __________________ board feet of softwood lumber
during the period January 1 through December 31, 20XX, and am currently a
domestic manufacturer or importer of softwood lumber.
Do not include softwood lumber exported from the United States.
(One cubic meter = 423.7760007 board feet)
**USDA may request documentation to support the volume above.

To be counted, completed ballots must be received by the
U.S. Department of Agriculture on Month XX, 20XX, by
4:30 p.m. Eastern Time.
NOTE: Only one vote will be counted for each eligible domestic
manufacturer 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 continuance/amendment of the Softwood
Lumber Research, Promotion, Consumer Education
and Industry Information Order?

YES 

NO 

III. CERTIFICATION AND SIGNATURE
ALL BALLOTS MUST BE SIGNED 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 manufacture or importation of softwood
lumber, I also CERTIFY that I have the authority to cast this ballot.
X

______________________________
SIGNATURE
ENTITY NAME

_____________
DATE
________________________________
BUSINESS TELEPHONE NUMBER

IV. MAILING
Return ballot in the enclosed, postage-paid envelope.
SWL-ORB (rev. 03/17) Destroy previous edition.

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.
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) 6907442; or 3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

SWL-ORB (rev. 03/17) Destroy previous edition.