SC-72 (987) CA 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

SPECIALTY CROPS 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).

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.

Final Decision – Dates

The undersigned hereby authorizes the Deputy Administrator, or the Acting Deputy Administrator, Specialty Crops Program, 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.

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.

SC-72 (Rev. 01/2017) Destroy previous editions.