SC-651 929-Cranberry M.O. Member & Alternate Member Ballot Form

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

CRANBERRY MARKETING COMMITTEE

MEMBER AND ALTERNATE MEMBER BALLOT

I hereby cast my Ballot for two (2) of the following nominees to serve as one member and one alternate member to represent growers from Cranberry Marketing Order District No. _____ who are not from major cooperatives, on the Cranberry Marketing Committee during the term of office that begins

August 1, 20___. Mark the Ballot for two of the nominees listed below by placing an X in the box next to the nominee’s name.

NOMINEES

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I certify that I am a producer of cranberries in District No. _____. (Please specify District Number.)

District 1: the States of Massachusetts, Rhode Island and Connecticut; District 2: the States of New Jersey and Long Island in the State of New York; District 3: the States of Wisconsin, Michigan and Minnesota; and District 4: the States of Oregon and Washington.

Name of person voting

Signature of person voting

Ballots must be postmarked by _________ in order to be counted.

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 OMB 0581-0189. The time required to complete this information collection is estimated to average 5 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.

SC-651 (Exp. X/XXXX) Destroy previous editions.