Form DA-21-R Fluid Milk Promotion Order Continuance Referendum (Proce

OFFICIAL REFERENDUM BALLOT:

OMB NO. 0581-0093

United States Department of Agriculture
Agricultural Marketing Service
Dairy Programs
FLUID MILK PROMOTION ORDER CONTINUANCE REFERENDUM
FLUID MILK PROCESSORS

FLUID MILK PROMOTION ORDER

See the reverse of this form for instructions for completing the ballot. This ballot and the information provided will
be kept confidential. (Please type or print.)

Processor Name

Processor Address

State

City

Zip Code

BALLOT: DO YOU FAVOR CONTINUATION OF THE FLUID MILK PROMOTION ORDER?
(Place an “X” in only one space)

□ YES, continue the Order
□ NO, terminate the Order

I hereby CERTIFY that the name and address above are correct and that I am eligible to vote as set forth on the
reverse side of this ballot. My signature below certifies that I have the authority to act on behalf of this organization.

Name (Please Type or Print)

Signature

Title

Date

FALSIFICATION OF INFORMATION ON THIS GOVERNMENT DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN
$10,000 OR IMPRISONMENT FOR NOT MORE THAN 5 YEARS, OR BOTH (18 U.S.C. 1001)

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Form DA-21-R (Rev. 02/17) Destroy all previous editions.

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OFFICIAL REFERENDUM BALLOT Instructions

OMB NO. 0581-0093

Fluid Milk Promotion Order Continuance Referendum
The Fluid Milk Promotion Act of 1990 (Title XIX, subtitle H, of the Food, and Agriculture, Conservation, and Trade Act of
1990, Pub L. 1001-624) authorized the establishment of a national program for fluid milk promotion. This program is funded by
a 20-cent per hundredweight assessment on fluid milk products processed and marketed commercially in consumer-type packages
in the 48 contiguous United States and the District of Columbia by fluid milk processors, excluding deliveries directly
to the residence of consumers. A board of 20 members, 15 who represent geographic regions and five at-large members, has
been appointed by the Secretary of Agriculture to administer the Order.
The Act requires the Secretary to conduct a continuation referendum among fluid milk processors to determine if they approve
the continuation or termination of the Fluid Milk Promotion Order. Continuation of the Order is contingent upon approval by at
least 50 percent of the fluid milk processors voting. Those voting for approval also must have processed and marketed
collectively 60 percent or more of the fluid milk products marketed in the United States by processors participating in the
referendum.
I. Referendum Period. Voting will be conducted by mail beginning
Ballots postmarked after
will not be counted.

through

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II. Processors Eligible to Vote Must Meet ALL of the Following Conditions:
1. Be registered by
.
2. Have processed and marketed commercially at least 3,000,000 pounds of fluid milk products in consumer-type packages in
the United States during
excluding deliveries directly to the residence of consumers.
3. Be processing and marketing fluid milk products in consumer-type packages in the United States:
a. At the time of voter registration, and
b. At the time of voting.
III. Instructions for Completing the Ballot.
1. Vote in the space provided.
2. Type or print your name and title, sign, and date the ballot.
3. Correct the printed mailing address, if necessary.
4. Mail the ballot in the pre-addressed envelope so that it is postmarked during the period of
If you do not have a pre-addressed envelope, mail the ballot to:

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Referendum Agent
USDA, AMS, Dairy Programs
Room 2968-S, Mail Stop 0225
1400 Independence Avenue SW
Washington, D.C. 20250-0225
If you have questions or need information on the referendum, call the Referendum Agent at (202) 720-6909.
According to the Paperwork Reduction Act of 1995, an agency my 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 0581-0093. The
time required to complete this information collection is estimated to average 6 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.
Form DA-21-R (Rev. 02/17) Destroy all previous editions.

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