HON-ORB Honey Official Referendum Ballot

OMB No. 0581-0093

United States Department of Agriculture
Agricultural Marketing Service

I. CERTIFICATION
1. I am currently a honey FIRST HANDLER  and/or IMPORTER  (Check one),
during the period XXX, 20XX, to XXX, 20XX.

OFFICIAL REFERENDUM BALLOT
Honey Packers and Importers Research, Promotion,
Consumer Education and
Industry Information Order
To be counted, completed ballots must be received by
the U.S. Department of Agriculture by X:XX p.m.
Eastern Time on XXX, 20XX.
NOTE: Only one vote will be counted for each eligible
handler and importer. Incomplete ballots will be
INVALID and will not be counted in the referendum.

2. I handled and/or imported
between XXX, 20XX and XXX, 20XX.

pounds of honey or honey products

Preprinted totals for handlers include honey handled and reported by XXX. Totals for
importers include honey imports reported by U.S. Customs. If corrections need to be
made, please cross out and legibly write in the correct information. Submit
documentation to support these changes along with your ballot to USDA.
II. VOTE
Instructions: Mark one box only.

Do you favor continuance of [amendment to] the Honey Packers and
Importers Research, Promotion, Consumer Education and Industry
Information Order?

YES 

NO 

III.
SIGNATURE
ALL BALLOTS MUST BE SIGNED AND DATED BELOW IN ORDER TO BE
COUNTED.
I CERTIFY that I am the person authorized to cast this ballot and 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 honey or honey
products, I also CERTIFY that I have the authority to cast this ballot.

X ____________________________________
SIGNATURE
____________________________________
COMPANY NAME

________________
DATE
_____________________________
BUSINESS TELEPHONE NUMBER

Return ballot in the enclosed, postage-paid envelope.

HON-ORB (Rev. 03/17) Destroy previous editions.

OMB No. 0581-0093

Title 18, Section 1001 United States Code (False Statements)
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.

Privacy Act and Paperwork Reduction Act Statement.
The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The
authority for requesting this information to be supplied on this form is from the applicable commodity legislation for research and promotion programs.
Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or importer
identification number is mandatory and will be used to determine affiliation or entity identity.
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 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.

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) 6907442; or 3) email: [email protected].
USDA is an equal opportunity provider, employer, and lender.

HON-ORB (03/17) Destroy previous editions.

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