PAP-ORB Paper Board Referendum Ballot

APPROVED - OMB NO. 0581-0093

United States Department of Agriculture Agricultural Marketing Service OFFICIAL REFERENDUM BALLOT Paper and Paper-Based Packaging Promotion, Research, and Information Order Complete Sections I, II, and III of this ballot. To be counted, completed ballots must be received by the U.S. Department of Agriculture no later than Month xx, 20xx, by 4:30 p.m. Eastern Time. NOTE: Only one vote will be counted for each eligible domestic manufacturer and importer. Incomplete ballots may be INVALID and may not be counted in the referendum.	I. ELIGIBLITY I Manufactured within the United States or Imported to the United States __________________ short tons of paper and paper-based packaging during the period Month xx, 20xx, through Month xx, 20xx, and am currently a domestic manufacturer or importer of paper and paper-based packaging. **USDA may request documentation to support the volume above.
	II. VOTE Instructions: Mark one box only. Do you favor the (continuance/amendment) of the Paper and Paper-Based Packaging Promotion, Research and Information Order? YES  NO 
	III. CERTIFICATION AND SIGNATURE ALL BALLOTS MUST BE SIGNED 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 manufacture or importation of paper and paper-based packaging, I also CERTIFY that I have the authority to cast this ballot. X _____________________________ __________________________ SIGNATURE DATE ________________________________ ENTITY NAME BUSINESS TELEPHONE NO.
	IV. MAILING Return ballot in the enclosed, postage-paid envelope.

APPROVED - OMB NO. 0581-0093

FALSIFICATION OF INFORMATION OR MISREPRESENTATION OF IDENTITY 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)

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

PAP-ORB (Expiration Date XX/XX/20XX) See reverse for burden/non-discrimination statement