Form MAN-ORB Mango Official Referendum Ballot

FORM APPROVED OMB NO. 0581-0093

United States Department of Agriculture
Agricultural Marketing Service
OFFICIAL REFERENDUM BALLOT
Mango Promotion, Research, and
Information Order
To be counted, completed ballots must be received by the
U.S. Department of Agriculture on Month xx, 20XX and
before ____ p.m. Eastern Time.

NOTE: Only one vote will be counted for each
eligible first handler and importer. Incomplete
ballots may be INVALID and may not be counted in
the referendum.

I. ELIGIBILITY
Please check.
_______

I am currently a FIRST HANDLER or an IMPORTER of fresh
mangos and I handled 500,000 or more pounds of fresh mangos between
January 1, 20XX and December 31, 20XX.

II. VOTE
Instructions: Mark one box only.

Do you favor the continuance of [amendment to] the Mango
Promotion, Research, and Information Order?

YES 

NO 

III. CERTIFICATION AND SIGNATURE
ALL BALLOTS MUST BE SIGNED BELOW IN ORDER TO BE COUNTED.
I CERTIFY 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 handling or importation of mangos, I also CERTIFY that I have the authority to cast
this ballot and will submit evidence thereof if so requested by the Referendum Agent.
X ____________________________________

______________________

SIGNATURE

DATE

_______________________________________
COMPANY NAME

(______)_________-_________
BUSINESS TELEPHONE NUMBER

IV. MAILING
Return ballot in the enclosed, postage-paid envelope.
MAN-ORB (Rev. 03/17) Destroy previous versions.

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.
According to the Paperwork Reduction Act of 1995, an agency may or 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 the information collection is 05810093. 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.

MAN-ORB (Rev. 03/17) Destroy previous versions.