SWL-BAL Softwood Lumber--Ballot

Form Approved – OMB No. 0581-0093

SOFTWOOD LUMBER BOARD
SOFTWOOD LUMBER RESEARCH, PROMOTION, CONSUMER
EDUCATION AND INDUSTRY INFORMATION ORDER
BALLOT—____________________ (specify region)
INSTRUCTIONS:
The nominees listed on this ballot are seeking (a large/small) company seat(s) on the Softwood
Lumber Board (Board) representing the _______ Region. The _______ Region consists of
_______________.
Large means manufacturers for the U.S. market who account for the top two-thirds of the total annual
volume of assessable softwood lumber and small means those who account for the remaining one-third
of the total annual volume of assessable softwood lumber.
If your company operates in more than one region you may choose the region in which you cast a
vote, but you may vote in no more than one region. Appropriate ballot(s) have been provided in
this package. If there’s any question please call 202-463-4705. Submit no more than one ballot.
Please complete ballot AND certification statement and mail it back to the Board in the
enclosed, self-addressed envelope.
Ballots must be submitted by mail. Do not fax or email the ballot. Ballots must be
postmarked on or before (date). Ballots postmarked after that date will not be counted.

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.

SWL-BAL (rev. 03/17) Destroy previous edition.

Form Approved – OMB No. 0581-0093

NOTE: 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.
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.

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Form Approved – OMB No. 0581-0093

SOFTWOOD LUMBER BOARD
BALLOT – __________ REGION – (LARGE/SMALL COMPANY SEAT)
Choose ___ (#) candidates only.
CANDIDATES
[ ]

Name, company, state/province

[ ]

Name, company, state/province

[ ]

Name, company, state/province

[ ]

________________________________________(Write in)
Print Candidate Name

PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:
I certify that I domestically manufactured and shipped within the United States or imported to the
United States a minimum of 15 million board feet of softwood lumber during the twelve-month
period of (date) through (date) and that I manufactured and domestically shipped or imported softwood
lumber from the ________Region:
Signature: ____________________________________________________________
Print Name: ___________________________________________________________
Company/Entity:__________________________________________________
Phone: ____________________________
Submission of Ballot to Board
Once you have completed and signed this ballot please place this ballot in the enclosed, self-addressed
envelope and mail it to the Board. Ballots may not be counted if incomplete. Ballots postmarked
after
(date) will not be counted.
RETURN BALLOT TO: (ADDRESS)

SLB – XXX (20xx)
X Company
SWL-BAL (rev. 03/17) Destroy previous edition.