DA-21 Dairy Continuance Referendum (Producers- Importers)

OFFICIAL REFERENDUM BALLOT: OMB NO. 0581-0093

United States Department of Agriculture Agricultural Marketing Service

Dairy Programs

DAIRY PROMOTION AND RESEARCH ORDER CONTINUANCE REFERENDUM INDIVIDUAL PRODUCERS AND IMPORTERS DAIRY PROMOTION AND RESEARCH ORDER

See the reverse of this form for instructions for completing the ballot. This ballot and the information provided will be kept confidential. (Please type or print.)

Last Name of Producer or Importer Middle Initial First Name (Business Name, if applicable)

Business Address

City State Zip Code

BALLOT: DO YOU FAVOR HAVING THE SECRETARY OF AGRICULTURE CONTINUE THE DAIRY PROMOTION AND RESEARCH ORDER?

□ YES, continue the Order (Place an “X” in only one space) □ NO, terminate the Order

_{I hereby CERTIFY that during} I was engaged in the production or importation of dairy products or milk for commercial use; and

(CHECK ONLY 1 BLOCK)

□(A) I am a member of the cooperative association named below that marketed my milk:

□(B) No cooperative association marketed my milk and I sold my milk to the plant named below:

□(C) I sold my milk directly to consumers under the following business name:

□(D) I imported milk or dairy products into the U.S. under the following business name: Cooperative, plant, or business name of (A), (B), (C) or (D) above

City and State of Cooperative, plant, or business named above

If this ballot is being cast on behalf of any group of individuals, partnership, corporation, or other business entity engaged in the production or import of dairy products or milk for commercial use, I CERTIFY that I have the authority to cast this ballot and will submit evidence thereof if so requested by the Referendum Agent.

Name of Ballot Caster (Please Type or Print) Signature Date

FALSIFICATION OF INFORMATION ON THIS GOVERNMENT DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN

$10,000, IMPRISONMENT FOR NOT MORE THAN 5 YEARS, OR BOTH (18 U.S.C. §1001).

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According to the Paperwork Reduction Act of 1995, an agency my 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.

DA-21 (Expiration Date XX/XX/20XX) Page 2 of 3

OFFICIAL REFERENDUM BALLOT Instructions OMB NO. 0581-0093

Dairy Promotion and Research Order Continuance Referendum

A national Order establishing a dairy promotion, research, and nutrition education program was authorized by the Dairy and Tobacco Adjustment Act of 1983 and was fully implemented on May 1, 1984. The program provides for a 15-cent per hundredweight assessment on all milk produced in the United States and marketed commercially by dairy farmers. The 2008 Farm Bill specifies a mandatory assessment rate of 7.5 cents per hundredweight of milk or equivalent thereof on dairy products imported into the U.S.A. board of 38 dairy farmers and importers, appointed by the Secretary of Agriculture, administers the program.

The Secretary of Agriculture, pursuant to §116 of the Dairy and Tobacco Adjustment Act of 1983, has called for a referendum among producers and importers during to determine whether the Dairy Promotion and Research Order should be continued. For the program to continue, a majority of producers and importers voting in the referendum must favor keeping the program.

The Referendum Agent has established the referendum period as through . The Act requires that a cooperative association that votes on behalf of its members must advise its producer or importer members no later than 30 days prior to the beginning of the referendum as to how it will vote. The Referendum Agent has determined that to meet the notice requirement such cooperative must inform it’s members by _____________ A producer or importer member who opposes the cooperative’s vote may cast an official individual producer or importer ballot with the member’s differing vote.

1. Voting. Voting will be conducted by mail. The Referendum Agent has determined that completed ballots must

be postmarked through as specified in the Referendum Order. Incomplete ballots or ballots postmarked earlier or later than the dates specified in the Referendum Order will not be counted.

2. Persons Eligible to Vote. A producer engaged in the production or an importer of dairy products, or milk for commercial use during is eligible to vote. In the case of a producer or importer who is other than an individual, the business unit is regarded as the producer or importer. Only one vote is permitted for each dairy farm or importer business unit. A cooperative association may vote on behalf of its producer or importer members. A producer or importer member opposed to the cooperative vote may cast an individual ballot.

3. Instructions for Completing the Ballot.

1. Complete the producer or importer name and business name (if applicable) including address.

2. Vote in the space provided.

3. Complete the certification section. A producer who is a member of or under contract to a cooperative should check block (A) and indicate the name and address of the cooperative. A producer who does not market milk through a cooperative should check block (B) and indicate the name and address of the plant to which the producer sells milk. A producer who sells milk directly to consumers should check block (C) and indicate the name and address of the distribution business.

4. Be sure to sign the ballot.

5. Mail the ballot in the return envelope not later than the date specified in the Referendum Order. If you did not obtain a return envelope, mail your ballot to:

Referendum Agent

USDA, AMS, Dairy Programs Room XXXX-S, Mail Stop XXXX STREET

City, State, Zip

If you have questions or need information, on the referendum, call the Referendum Agent at (XXX) XXX-XXXX.

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