100 Riverside Parkway, Suite 101

Fredericksburg, Virginia 22406

CN-100, Attachment A (Expiration Date 12/31/2021)

 Form Approved

OMB No. 0581-0093

To request a continuance referendum, please complete the attached form and include a copy of at 

least one sales receipt from calendar year 2020 and return these documents to USDA, AMS, 

Cotton and Tobacco Program, Attention: Cotton Sign-Up, P.O. Box 23181, Washington, 

DC 20077-8249. For your signature to be counted during the sign-up period, your request must 

be received no later than October 29, 2021. 

No action is necessary if a continuance referendum is not desired.

I, _______________________________________________ request that the U.S. Department of 

 (PRINT FULL NAME)

Agriculture conduct a continuance referendum regarding the 1991 amendments to the Cotton 

Research and Promotion Order.

_______________________________

Print Name

______________________________________________________________________________

Address

_______________________________ __________________

Signature Date

_______________________________

Company Name
CN-100, Attachment A (Expiration Date 12/31/2021)

2

BURDEN AND NONDISCRIMINATION STATEMENTS

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-

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: program.intake@usda.gov. 

USDA is an equal opportunity provider, employer, and lender.