SC-269 Producer Nomination Ballot (Dist.1) CA Olive Cmte (932)

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0178

Ballot No. __________

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

PRODUCER NOMINATION BALLOT

CALIFORNIA OLIVE COMMITTEE

DISTRICT NO. 1: Counties of Alpine, Tuolumne, Stanislaus, Santa Clara, Santa Cruz,

and all counties north thereof:

MEMBER CANDIDATES [VOTE FOR THREE (3)]		ALTERNATE CANDIDATES [VOTE FOR THREE (3)]

I certify that I am authorized to vote on behalf of the producing entity and that such producing entity delivered or intended to deliver olives for use as packaged olives for the 20___ - 20___ crop year.

THE BALLOT IS NOT VALID (AND WILL NOT BE COUNTED) IF THE PRODUCER NAME, SIGNATURE, AND ADDRESS ARE NOT ON THE RETURN ENVELOPE.

Return in envelope provided to: California Olive Committee

770 E. Shaw Avenue, Suite 310

Fresno, CA 93710

BALLOTS MUST BE POSTMARKED NO LATER THAN _____________, 20__.

This information is used to verify the provisions of the Marketing Order, 7 CFR 932.129. Making any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, which provides for penalty or imprisonment, or both.

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 OMB 0581-0178. 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: (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.

SC-269 (Rev. 01/2017) Destroy previous editions.