SC-261 Blueberry Referendum Ballot

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. 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.

SC-261 (rev. 03/17) Destroy previous editions.

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)

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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-261 (rev. 03/17) Destroy previous editions.