SC-3 MOAD - Amendatory Ballot (Cooperative)

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB 0581-0178

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

OFFICIAL PRODUCER AMENDATORY BALLOT

Marketing Order No._____:

PART I - REFERENDUM INSTRUCTIONS

1. REFERENDUM PERIOD: ______________, 20___ through ______________, 20___ is period during which producers may vote on the proposed amendments to the marketing order regulating the handling of_________________. For amendments to the marketing order to pass, they must be supported by at least ______________of the growers voting and/ or at least _______ of the volume represented by those voting in the Referendum.

B. ELIGIBILITY REQUIREMENTS: Any person who produced ________ for market during the period of ______________ through _______________, and who is now a producer, is eligible to vote. Such persons may vote on the items (1) through (___) using the attached ballot.

1. A producer is defined as: (a) any person who produces ________________ in the designated production area; (b) a renter or tenant of acreage producing ___________ for market; or (c) a landlord who received from a renter or tenant ________ as rent for the land on which such _______ were grown. A cash landlord, lienholder, or person having only a financial interest in the crop is not an eligible voter.

2. A business unit, partnership, family enterprise, corporation, association, estate, or firm may vote. Each such entity is entitled to one vote.

3. If you believe you are eligible to submit more than one ballot, additional ballots may be obtained by contacting the __________ Marketing Field Office at (­____) _____-________

4. If ballot is cast by an officer or employee of a partnership, LLC, corporation, association or other business unit, check box to indicate your business designation, and sign to indicate authority to vote. If partnership or joint venture, list names of partners.

5. Proxy voting is not authorized

C. INSTRUCTIONS FOR VOTING:

1. Complete the voter information (Part II) and the voter certification of eligibility (Part IV)

2. Indicate your vote by placing an “X” in the appropriate box (Part III).

3. Incomplete or unsigned ballots cannot be counted.

Sign below the certification. Incomplete or unsigned Ballots cannot be counted. Fold your Ballot so the Referendum Agent’s address is displayed, seal with tape and mail the completed ballot in the enclosed envelope and return to:

__________ Marketing Field Office

USDA-AMS-SCP

Address: _________

City/ State: ___________

For further information, please call (___) ____-_______.

Ballots must be received ___ days after _______________, 20____.

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 0581-0178. The time required to complete this information collection is estimated to average 20 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.

__________ ________ BALLOT

UNITED STATES DEPARTMENT OF AGRICULTURE

Agricultural Marketing Service

Specialty Crops Program

Marketing Field Office

____________

____________

___________

___________

BALLOT

_____________________________________________________________________________________

TO ______ _______ PRODUCERS:

The U.S. Department of Agriculture is submitting for producer consideration proposed amendments to Marketing Order No. ___ (Order), regulating the handling of ______ grown in _____. The proposed amendments will not be made effective unless they are favored by at least ______ of the eligible producers voting in this Referendum or by producers representing at least ______ of the volume of English walnuts voted in the Referendum. If approved, the proposed amendments would:

_____________________________________________________________________

A Producer Referendum Ballot is on the reverse side of this page. Also enclosed are:

1. Voting Instructions and Rules Governing Producer Eligibility to Vote;

2. The news release announcing the Referendum; and

3. A copy of the Referendum Order dated _______________________________________, 20___.

The voting period for the referendum is ___________________________, 20___. Please vote promptly because Ballots postmarked later than __________________, 20___, cannot be opened or counted. Each Ballot will be held in strict confidence.

____________________________________

Referendum Agent

Phone: (____) ____-_____

.

OFFICIAL PRODUCER AMENDATORY BALLOT

Marketing Order No._____:

PART II - VOTER INFORMATION

A. Name:________________________________________________________________________________

(Please print clearly)

B. What is the specific location of your ______________ represented in this ballot?

(Street Address, County(ies))

(City, State, and ZIP code)

C. If you are not voting as an individual producer, please check the appropriate box indicating your voting status and write the name and address of the business unit you represent.

 Partnership  Corporation  Other (Specify) ______________________________________

Business Name: ________________________________________________________________________________

Business Address: ______________________________________________________________________________

If Partnership or Joint Venture, list name(s) ___________________________________________________

D. What is the volume (cartons, pounds, tons) produced during the period of _________ through __________? _______ volume.

E. Total number of acres of______________ represented by this ballot: _______ acres.

F. Which handler(s) handled your ______________ during this period?

(Name of handler(s))

(Street Address, County)

Don’t forget to mark your vote and sign your ballot

Incomplete or unsigned ballots cannot be counted!

This ballot must be completed fully with attachments and returned

by ______, 20__ to be valid.

OFFICIAL PRODUCER AMENDATORY BALLOT

Marketing Order No._____:

PART III - REFERENDUM ISSUES

“YES” vote means you favor the change; “NO” vote means you oppose the change.

MARKETING ORDER AMENDMENTS:	YES	NO

PART IV - VOTER CERTIFICATION OF ELIGIBILITY

All information provided in this ballot will be subject to on-site verification by officials of the Office of Inspector General, U.S. Department of Agriculture.

The information on this ballot is required to determine the voter eligibility. Falsification of information on this government document may result in a fine of not more than $10,000, or imprisonment for not more than five (5) years, or both (18 U.S.C. 1001).

A. If signing as an individual.

I am the grower named in Part II of this ballot, and I certify that I am not a cash landlord, lienholder, or person having only a financial interest in the crop, and that the information provided on this ballot and any attachment hereto is accurate and correct to the best of my knowledge.

______________________________________________________ ________________________________

(Signature of Producer or Authorized Person) Date

B. If signing as the representative of a producing entity other than an individual, designate your title and sign below.

If you are a partner casting the ballot for a partnership; an officer or employee casting the ballot for a cooperative association, corporation, school, institution, or similar business unit, or the administrator executor, or trustee casting the ballot for a producing estate, but singing this ballot you agree to provide evidence thereof at the request of an authorized agent of the Secretary.

I hereby certify that I am duly authorized to vote on behalf of the producing entity named in Part II of this ballot and that the information provided in this ballot and any attachment hereto is accurate and correct to the best of my knowledge.

_________________________________ _______________________________ __________________________

(Signature) (Title of Person Signing) (Date)

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.

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