Form SC-269 Producer Nomination Ballot (Dist.1) CA Olive Cmte (932)

REPRODUCE LOCALLY. Include form number and date on all reproductions.

OMB No. 0581-0178

Ballot No. __________
UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
SPECIALTY CROPS PROGRAM
PRODUCER NOMINATION BALLOT
CALIFORNIA OLIVE COMMITTEE
DISTRICT NO. 1: Counties of Alpine, Tuolumne, Stanislaus, Santa Clara, Santa Cruz,
and all counties north thereof:
MEMBER CANDIDATES
[VOTE FOR _____ (__)]

ALTERNATE CANDIDATES
[VOTE FOR _____ (__)]

I certify that I am authorized to vote on behalf of the producing entity and that such producing entity
delivered or intended to deliver olives for use as packaged olives for the 20___ - 20___ crop year.
THE BALLOT IS NOT VALID (AND WILL NOT BE COUNTED) IF THE PRODUCER NAME,
COMPANY NAME, & SIGNATURE IS NOT COMPLETED BELOW.
Return in envelope provided to:

California Olive Committee
2565 Alluvial Avenue, Suite 152
Clovis, CA 93611

BALLOTS MUST BE POSTMARKED NO LATER THAN _____________, 20__.
Print Name: ___________________________________________________________________
Company Name: _______________________________________________________________
Signature: ____________________________________________________________________
This information is used to verify the provisions of the Marketing Order, 7 CFR 932.129. Making any false statements or
representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of
title 18, section 1001, of the United States Code, which provides for penalty or imprisonment, or both.
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
0581-0178. 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, 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.

SC-269 (Exp. 4/30/2027) Destroy previous editions.

REPRODUCE LOCALLY. Include form number and date on all reproductions.

OMB No. 0581-0178

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: program.intake@usda.gov. USDA is an equal opportunity provider,
employer, and lender.

SC-269 (Exp. 4/30/2027) Destroy previous editions.