LP-51-1 Soybean Request for Referendum

OMB NO. 0581-0093

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SOYBEAN PROMOTION AND RESEARCH ORDER REQUEST FOR REFERENDUM

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.

CERTIFICATION STATEMENT

I HEREBY CERTIFY that I am a soybean producer or producer entity that I am authorized to represent and have paid an assessment sometime during , through . I am requesting a referendum 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 to the best of my knowledge and belief. Failure to provide supporting documentation showing that a soybean assessment was paid and complete and sign this form will invalidate the request.

_{NAME OF INDIVIDUAL PRODUCER OR OTHER PRODUCER ENTITY (Print)}

_{ADDRESS (Street, P.O. Box, or Route No., City, State, ZIP Code)}

_{TELEPHONE NUMBER (Including Area Code) COUNTY}

IMPORTANT: Sign and date this form if you wish to request a referendum on the Soybean Promotion and Research

_Order.

_{SIGNATURE OF PRODUCER OR REPRESENTATIVE OF PRODUCER ENTITY DATE}

_{TITLE (If applicable)}

LP-51-1 (Expiration Date XX/XX/XXXX)