DA-21 Dairy Continuance Referendum (Producers)

OFFICIAL REFERENDUM BALLOT:

OMB NO. 0581-0093

United States Department of Agriculture
Agricultural Marketing Service Dairy
Programs
DAIRY PROMOTION AND RESEARCH ORDER CONTINUANCE REFERENDUM
INDIVIDUAL PRODUCERS AND IMPORTERS

DAIRY PROMOTION AND RESEARCH 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.)

Last Name of Producer or Importer

Middle Initial

First Name

(Business Name, if applicable)

Business Address

City

State

Zip Code

BALLOT: DO YOU FAVOR HAVING THE SECRETARY OF AGRICULTURE CONTINUE
THE DAIRY PROMOTION AND RESEARCH ORDER?

□ YES, continue the Order

(Place an “X” in only one space)

□ NO, terminate the Order

I was engaged in the production or importation of dairy products

I hereby CERTIFY that during
or milk for commercial use; and

(CHECK ONLY 1 BLOCK)

□ (A) I am a member of the cooperative association named below that marketed my milk:
□ (B) No cooperative association marketed my milk and I sold my milk to the plant named below:
□(C) I sold my milk directly to consumers under the following business name:
□(D) I imported milk or dairy products into the U.S. under the following business name:
Cooperative, plant, or business name of (A), (B), (C) or (D) above
City and State of Cooperative, plant, or business named above
If this ballot is being cast on behalf of any group of individuals, partnership, corporation, or other business entity
engaged in the production or import of dairy products or milk for commercial use, I CERTIFY that I have the
authority to cast this ballot and will submit evidence thereof if so requested by the Referendum Agent.

Name of Ballot Caster (Please Type or Print)

Signature

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

(FRONT PAGE)

OFFICIAL REFERENDUM BALLOT Instructions

OMB NO. 0581-0093

Dairy Promotion and Research Order Continuance Referendum
A national Order establishing a dairy promotion, research, and nutrition education program was authorized by the Dairy and Tobacco
Adjustment Act of 1983 and was fully implemented on May 1, 1984. The program provides for a 15-cent per hundredweight
assessment on all milk produced in the United States and marketed commercially by dairy farmers. The 2008 Farm Bill specifies a
mandatory assessment rate of 7.5 cents per hundredweight of milk or equivalent thereof on dairy products imported into the U.S. A
board of 38 dairy farmers and importers, appointed by the Secretary of Agriculture, administers the program.
The Secretary of Agriculture, pursuant to Section 116 of the Dairy and Tobacco Adjustment Act of 1983, has called for a referendum
among producers and importers during
to determine whether the Dairy Promotion and Research Order
should be continued. For the program to continue, a majority of producers and importers voting in the referendum must favor keeping
the program.
The Referendum Agent has established the referendum period as
through
. The Act requires that a
cooperative association that votes on behalf of its members must advise its producer or importer members no later than 30 days prior
to the beginning of the referendum as to how it will vote. The Referendum Agent has determined that to meet the notice requirement
such cooperative must inform it’s members by
. A producer or importer member who opposes the
cooperative’s vote may cast an official individual producer or importer ballot with the member’s differing vote.

I. Voting. Voting will be conducted by mail. The Referendum Agent has determined that completed ballots must
be postmarked
through
as specified in the Referendum Order. Incomplete ballots or ballots
postmarked earlier or later than the dates specified in the Referendum Order will not be counted.

II. Persons Eligible to Vote. A producer engaged in the production or an importer of dairy products, or milk for
commercial use during
is eligible to vote. In the case of a producer or importer who is other than an
individual, the business unit is regarded as the producer or importer. Only one vote is permitted for each dairy farm or
importer business unit. A cooperative association may vote on behalf of its producer or importer members. A producer
or importer member opposed to the cooperative vote may cast an individual ballot.

III. Instructions for Completing the Ballot.
1. Complete the producer or importer name and business name (if applicable) including address.
2. Vote in the space provided.
3. Complete the certification section. A producer who is a member of or under contract to a cooperative should check
block (A) and indicate the name and address of the cooperative. A producer who does not market milk through a
cooperative should check block (B) and indicate the name and address of the plant to which the producer sells milk.
A producer who sells milk directly to consumers should check block (C) and indicate the name and address of the
distribution business.

4. Be sure to sign the ballot.
5. Mail the ballot in the return envelope not later than the date specified in the Referendum Order. If you did not
obtain a return envelope, mail your ballot to:

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 (Rev. 02/17) Destroy previous editions.

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