Form VS-10-13 Owner/Shipper Certificate

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

OWNER/SHIPPER CERTIFICATE
FITNESS TO TRAVEL TO A SLAUGHTER FACILITY
(Please type or print in ink)
TIME HORSES LOADED ON CONVEYANCE

According to the Paperwork Reduction Act of 1995, no persons
are 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 0579-0160. The time
required to complete this information collection is estimated to
average .5 hours 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.

FORM
APPROVED
OMB NO.
0579-0160

CITY AND STATE WHERE HORSES WERE LOADED ON CONVEYANCE

DATE

VEHICLE LICENSE NO. AND DRIVER'S NAME

NAME OF AUCTION/MARKET

CONSIGNOR (OWNER/SHIPPER) NAME

CONSIGNEE (RECEIVER/DESTINATION) NAME

STREET ADDRESS

STREET ADDRESS

CITY, STATE, ZIP CODE

CITY, STATE, ZIP CODE

AREA CODE AND TELEPHONE NO.

AREA CODE AND TELEPHONE NO.

CHECK THE BOX THAT INDICATES THE FOLLOWING IS TRUE FOR ALL THE HORSES ON THIS CERTIFICATE
Pregnant mares are not likely to foal (give birth) during the trip.

Horses are able to bear weight on all 4 limbs.

Foals are older than 6 months of age.

Horses are not blind in both eyes.

TAG
PREFIX

Tag
NO.

COLOR DESCRIPTION
Bay

Grey

Blk.

BREED/TYPE

Pinto Chestn Other

TB

QT

Draft

Pony

Horses are able to walk unassisted.
SEX

Other

Mare

Stal

Geld

BRANDS
Tattoos, etc.

REMARKS
(Include existing
conditions)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
HORSES HAVE HAD ACCESS TO FOOD, WATER, AND REST FOR A MINIMUM OF 6 CONSECUTIVE
HOURS IMMEDIATELY BEFORE LOADING INTO CONVEYANCE.
SIGNATURE

CANADIAN FOOD INSPECTION AGENCY (CFIA)
EST.
DATE
TIME

I HEREBY AUTHORIZE THE CFIA TO DISCLOSE THIS DOCUMENT AND THE INFORMATION IN IT AS
COMPLETED BY THE CFIA OR DGIF TO THE USDA. FALSIFICATION OF THIS FORM OR KNOWINGLY
USING A FALSIFIED FORM IS A CRIMINAL OFFENSE AND MAY RESULT IN A FINE OF NOT MORE THAN
$10,000 OR IMPRISONMENT FOR NOT MORE THAN 5 YEARS OR BOTH (18 U.S.C. SECTION 1001).
SIGNATURE OF OWNER/SHIPPER (I certify that the information contained in this form is true and correct to
the best of my knowledge.)

DIRECCION GENERAL DE INSPECCION EN
FRONTERAS (DGIF)
EST.
DATE
TIME

VS FORM 10-13

(AUG 2004)

Previous editions are obslete

PAGE 1 OF ___

COPY DESIGNATIONS
in lower right corner in RED ink

PART 1 - Inspector
PART 2 - Owner/Shipper

OWNER/SHIPPER CERTIFICATE
FITNESS TO TRAVEL TO A
SLAUGHTER FACILITY

VS FORM 10-13