CN-100 Cotton Referendum Ballot & Ballot envelope

100 Riverside Parkway, Suite 101
Fredericksburg, Virginia 22406

Form Approved
OMB No. 0581-0093
To request a continuance referendum, please complete the attached form and return it to [Insert
USDA Farm Service Agency Address]. For your signature to be counted during the sign-up
period, your request must be received no later than [insert date]. No action is necessary if a
continuance referendum is not desired.

I, _______________________________________________ request that the U.S. Department of
(PRINT FULL NAME)
Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton
Research and Promotion Order.

_______________________________
Print Name

______________________________________________________________________________
Address

_______________________________
Signature

_______________________________
Company Name

CN-100, Attachment A (rev. 5-2017)

__________________
Date

2
BURDEN AND NONDISCRIMINATION STATEMENTS
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 05810093. 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.

CN-100, Attachment A (rev. 5-2017)

Notice XX-XXXX 
State: ______________________
In-Office Signup Sheet
_________________________
County FSA Signup Sheet

Page ______ of _______

Date 

Print Name 

Signature 

Remarks 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8.  

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

19. 

20. 

21. 

22. 

23. 

CN-100, Attachment B (rev. 5-2017)

24. 

25. 

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 05810093. 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.
USDA’s Nondiscrimination Statement
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.

CN-100, Attachment B (rev. 5-2017)

100 Riverside Parkway, Suite 101
Fredericksburg, Virginia 22406

Form Approved
OMB No. 0581-0093
To request a continuance referendum, please complete the attached form and include a copy of at
least one sales receipt and return these documents to the County FSA office where your farm is
located. For your signature to be counted during the sign-up period your request must be
received no later than XXXXXX. No action is necessary if a continuance referendum is not
desired.
I, _______________________________________________ request that the U.S. Department of
(PRINT FULL NAME)
Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton
Research and Promotion Order.

_______________________________
Print Name

______________________________________________________________________________
Address

_______________________________
Signature

_______________________________
Company Name

CN-100, Attachment C (rev. 5-2017)

__________________
Date

2
BURDEN AND NONDISCRIMINATION STATEMENTS
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 05810093. 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.

CN-100, Attachment C (rev. 5-2017)

100 Riverside Parkway, Suite 101
Fredericksburg, Virginia 22406

Form Approved
OMB No. 0581-0093

To request a continuance referendum, please complete the attached form and include a copy of one
U.S. Customs and Border Protection Form 7501 showing payment of a cotton assessment for
calendar year XXXXXX and return these documents XXXXXXX. For your signature to be counted
during the sign-up period your request must be received not later than XXXXXXX.
No action is necessary if a continuance referendum is not desired.

I, _______________________________________________ request that the U.S. Department of
(PRINT FULL NAME)
Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton
Research and Promotion Order.

_______________________________
Print Name

_______________________________
Signature

_______________________________
Company Name

CN-100, Attachment D (rev. 5-2017)

__________________
Date

2
BURDEN AND NONDISCRIMINATION STATEMENTS
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 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.

CN-100, Attachment D (rev. 5-2017)