AVO-ORB Hass Avocados Official Referendum Ballot

OMB No. 0581-0093

United States Department of Agriculture
Agricultural Marketing Service

OFFICIAL REFERENDUM BALLOT
Hass Avocado Promotion, Research, and Information Order

To be counted, completed ballots must be received by USDA on or after Month xx, 20xx and
before xx:xx p.m. Eastern Standard Time on Month xx, 20xx.
NOTE: Only one vote will be counted for each eligible producer and importer of fresh Hass avocados.
Incomplete and unsigned ballots will be INVALID and will not be counted in the referendum.

I. ELIGIBILITY (Check one)
______I am currently a fresh Hass avocado PRODUCER.
______I am currently an IMPORTER of fresh Hass avocados

II. VOTE (Mark one box)

Do you favor the continuance of [amendment to] the Hass Avocado Promotion, Research,
and Information Program?

Yes

No

III. CERTIFICATION 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 product or importation of Hass avocados, I also CERTIFY that I have the authority to cast
this ballot.

X _____________________________

_______________
DATE

SIGNATURE
_______________________________________

__________________________
BUSINESS TELEPHONE NUMBER

COMPANY NAME

IV. MAILING
Return ballot in the enclosed, postage-paid envelope.
The making of any false statement or representation on this form, knowing it to be false, is a violation of
Title 18, Section 1001 United States Code, which provides for the penalty of a fine of $10,000 or imprisonment
of not more than five years, or both.

AVO-ORB (Rev. 02/17) Destroy previous editions.

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 0581-0093. 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) 7202600 (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) 6329992. 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.

AVO-ORB (02/17) Destroy previous editions.