LP-49 Soybeans- Referendum Ballot

OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE

REFERENDUM ON THE SOYBEAN PROMOTION AND RESEARCH ORDER BALLOT

NOTE: INSTRUCTIONS TO VOTERS (Please read carefully)

1. If voting as an individual, you must vote in the county Farm Service Agency (FSA) Office in the county in which you reside, or the county FSA Office serving the county in which you reside.

2. If voting on behalf of an entity (partnership, corporation, estate, etc.) you must vote in the county FSA office in which it is located, or the county FSA office serving the county in which it is located.

3. Complete all sections.

Section A

Do you support continuation of the Soybean Promotion and Research Order?

_{Yes No}

Section B: Name and Address

Name of person or Other Entity Represented: (Print)

_{Address: (Street, P.O. Box, or Route No.)}

_{City: State: Zip Code:}

Section C: Certification Statement and Signature

I HEREBY CERTIFY that I am a person (any individual, group of individuals, partnership, corporation, association, cooperative or any other legal entity) or authorized representative and have engaged in the production of soybeans from:

_to

I am voting only once in the same capacity registered.

I FURTHER CERTIFY that the supporting documentation that I am providing along with this form is true, complete, and correct. FAILURE TO PROVIDE supporting documentation showing that the person voting was engaged in the production of soybeans as

indicated above, complete the ballot in its entirety, or provide a signature will invalidate this ballot.

_Signature

_{Title Date}

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.

LP-49 (Expiration Date XX/XX/XXXX) See reverse for continued burden/non-discrimination statement

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.

LP-49 (Expiration Date XX/XX/XXXX)

LP-49 (Exp. Date XX/XX/XXXX) OMB No. 0581-0093

Return Address

SOYBEAN REFERENDUM

Deadline for ARRIVAL at Farm Service Agency Office: ^{, 20__}

_L _j

4 1/8" x 9 1/2" Envelope