LPS-49 Soybeans- Referendum Ballot

FORM APPROVED. - OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

REFERENDUM ON THE SOYBEAN PROMOTION
AND RESEARCH ORDER BALLOT
NOTE: INSTRUCTIONS TO VOTERS (Please read carefully)
1. If voting as an individual, you must vote in the county Farm Service Agency (FSA) Office in the county in which you reside, or the county FSA Office
serving the county in which you reside.
2. If voting on behalf of an entity (partnership, corporation, estate, etc.) you must vote in the county FSA office in which it is located, or the county FSA office
serving the county in which it is located.
3. Complete all sections.

Section A
Do you support continuation of the Soybean Promotion and Research Order?

Yes

No

Section B: Name and Address
Name of person or Other Entity Represented: (Print)

Address: (Street, P.O. Box, or Route No.)

City:

State:

Zip Code:

Section C: Certification Statement and Signature
I HEREBY CERTIFY that I am a person (any individual, group of individuals, partnership, corporation, association, cooperative
or any other legal entity) or authorized representative and have engaged in the production of soybeans from:
to
I am voting only once in the same capacity registered.
I FURTHER CERTIFY that the supporting documentation that I am providing along with this form is true, complete, and correct.
FAILURE TO PROVIDE supporting documentation showing that the person voting was engaged in the production of soybeans as
indicated above, complete the ballot in its entirety, or provide a signature will invalidate this ballot.

Signature

Title

Date

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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.

LPS-49 (Rev. 04/17)

See reverse for burden/non-discrimination statement

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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
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