Cooperative Association Intent to Bloc Vote

Approved Form
OMB No. 0581-0032

COOPERATIVE ASSOCIATION
INTENT TO BLOC VOTE
XXX MARKETING AREA

Name of Qualified Cooperative Association
This signed form requires the designation of your cooperative association's voting intentions in the
referendum noted below.
A "No'' designation requires that we notify and send a ballot to each producer pooled on the
respective orders of your decision. A "Yes" designation indicates your intention to represent your
members (bloc vote). Failure to promptly respond will result in a "No" designation.

The cooperative association chooses to represent our members
(bloc vote) in the referendum for the decision described below:
(Check One)

YES
Signature and Title of Cooperative Association Official

NO
Date

Referendum pertaining to:
Docket:
Title:
Brief Description:
Hearing Dates:
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 0581-0032. 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) 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: mail: U.S. Department of Agriculture Office of the Assistant
Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; fax: (202) 690-7442; or email:[email protected].
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