VS 1-23 Appraisal and Indemnity Claim Form

APPRAISAL AND INDEMNITY CLAIM INSTRUCTIONS

Prepare separate claims for each VS Program disease. Do not include mortgaged and
non-mortgaged items in the same claim.

20. Record the value for the units described, (Item(s) in 18 X price in Item 19).
21. Obtained from VS Form 1-24 when animal carcass has been salvaged.

1. List the proper name of the VS Program disease involved.
22. Difference, self-explanatory.
2. Premises Identification number assigned by the State.
3. Herd/Flock Identification number assigned by the State.
4. List the herd/flock disease status designated by the State or VS Area Office.
5. Date(s) of slaughter or destruction of appraised animals or materials.
6. The date cleaning and disinfection was actually accomplished as evidenced by a
statement signed by the owner-claimant and on file, or a statement signed by a regulatory
representative who supervised the cleaning and disinfection. When cleaning and disinfection
is not required or is not indicated, insert an entry such as "Not Required" or "Open Range," no
"C&D" should be inserted.

23. & 24. Complete in accordance with specific instructions for the disease involved. Obtained
from the State or VS office.)
25. Source of pricing data and/or special factors affecting value of animals and/or materials.
Whenever a value is established for an animal or for a unit of material, or for a group of animals
or units of like class and value, a source of such value must be listed. This is especially
important when the appraised item has an unusual value. Some sources or factors used for this
purpose are: price at ___________________livestock market on (date) or price at a (named)
local source for animals of like quality and purpose; proven sire; bill of sale; trained; trained to
perform; production record of________lbs. in official test; proven breeder; pedigreed breeding
flock; primary breeding flock; multiplies flock; etc.
26. Date when materials/animals appraised and/or tagged and branded.

7. The proper legal name of the Owner-Claimant and the Owner-Claimant's complete mailing
address to include the building number and street, or RFD; city or town; State; and Zip code.
8. If joint ownership, give full name of all owners (do not list the name in Item 7 again). This
is not necessary if owned by a corporation.
9. Complete only when different then Item 7. The name and full address for the premises
where the appraisal was made.

27-29. Name, signature and title of a special expert appraiser whenever one is used to make the
appraisal.
30. Legal signature of the owner-claimant or authorized representative in Item 7 or 8. Must
agree with Item 7. NOTE: The applicable box in the "OWNER-CLAIMANT MORTGAGOR
CERTIFICATION" must be initialed prior to signature.
31. Title of person signing as claimant, e.g., owner, partner, manager, Vice President, etc.

10. County in which the premises is located. If in multiple counties, insert the name of the
county where the premises' mailing address (Item 9) is located.
11. For animals, report tag numbers, tattoos, electronic identification, or brands used, etc.
When indicated, use a description, e.g., "pheasant - golden"; parrot - Brazilian, trained and
talking", etc. For materials, any description that will reasonably identify the item, e.g., "wood
feed bunk."

32. Date signed, self-explanatory.
33-34. To be completed when animals are mortgaged. Separate claims for mortgaged and
non-mortgaged animals should be prepared.
35-38. This section must be completed by an authorized State or other local cooperating agency
official indicating the name of the State agency and official title.

12. Identify the species, e.g., cattle, sheep, bison, pig, chicken, parrot, etc.
13-15. Self-explanatory.
16. Insert "M" for materials, "G" for grade animal, or "R" for registered purebred or otherwise
entered in an Association or Society book and meeting program requirements for "registered
animals."

39-43. When all necessary information has been obtained, every element of the claim has been
substantiated and is filed with each claim, and every action has been completed, it should be
recommended for payment by the signature of the official or acting official in charge.
Completion of this section will imply certification as to the correctness of each claim, including
justifying statements in Item 25 and other substantiating documents in the station files.
44. Complete in all cases even when only one page is involved.

17. Describe unit, head, lb., cwt., ton, board foot, each, etc.
18. Report the number of animals or units/weight.
19. Price per head, lb., cwt., ton, board foot, each, etc.

VS 1-23 (REVERSE PART 5)
APR 2002

This information is required to be completed for the appraisal of
animals, for which indemnity is claimed. No monies or other
benefits may be paid out unless this report is completed and filed
as authorized under (9 CFR 51).

According to the Paperwork Reduction Act of 1985, no persons are required to respond to a collection of
information unless it displays a valid OMB number. The time to complete this collection of information is estimated
to average 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the form.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

The valid OMB control numbers for these
information collections are 0579-0047,
0579-0101, 0579-0137, 0579-0185, 0579-0189,
0579-0192, 0579-0199 ,0579-0305

1. VS PROGRAM DISEASE NAME

2. PREMISES IDENTIFICATION NO.

3. HERD/FLOCK IDENTIFICATION NO.

4. HERD/FLOCK DISEASE STATUS

5. DATE ANIMALS/MATERIALS DESTROYED

6. DATE OF CLEANING AND DISINFECTING

APPRAISAL AND INDEMNITY CLAIM FOR
ANIMALS DESTROYED

MATERIALS DESTROYED

7.a. OWNER-CLAIMANT LEGAL NAME

9.a. PREMISES WHERE APPRAISAL WAS MADE (If different from Item 7)

7.b. OWNER-CLAIMANT MAILING ADDRESS (Number & street, or RFD)

9.b. PREMISES ADDRESS (Number & street, or RFD)

7.c. CITY

9.c. CITY

7.d. STATE

7.e. ZIP CODE

9.d. STATE

9.e. ZIP CODE

8. IF JOINT OWNERSHIP, GIVE FULL NAME OF ALL OWNERS (If same as Item 7.a., so state)

APPRAISED
L
I
N
E

11.
DESCRIPTION/IDENTIFICATION/PAGE 12.
NO. OF VS FORM 1-23A (Description of SPECIES
Materials or Animal-reactor tag No., Animal ID
No., Tattoo, Tag, or Brand)

10. COUNTY

APPRAISAL
13.
AGE

14.
SEX

15.
BREED

16.
GRADE
PUREBRED/
MATERIALS

17.
UNIT
(head, lb,
ton, etc.)

18.
NO. UNITS/
WEIGHT

TOTAL APPRAISAL
19.
VALUE PER
UNIT

20.
21.
TOTAL APPRAISAL SALVAGE
VS FORM 1-24

AMOUNT DUE FROM

22.
DIFFERENCE

23.
UNITED STATES

24.
STATE AGENCY

1
2
3
4
5
25. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING VALUE OF
ANIMALS AND/OR MATERIALS

GRAND TOTALS
(Basis for payment)

OWNER-CLAIMANT MORTGAGOR CERTIFICATION

26. DATE ANIMALS/MATERIALS APPRAISED AND/OR TAGGED AND BRANDED

I certify that the animals and/or materials identified in this claim are (initials) ___ , are not (initials)____, not applicable _____(initials)
mortgaged. I further certify that I own or am authorized to represent the owner, or am otherwise the claimant, of the animals and/or materials
identified in this claim. I make claim for all amounts due me in accordance with all applicable laws and regulations governing the payment for
CERTIFICATION AND APPRAISAL CERTIFICATE
the animals and/or materials identified in this claim. I fully understand my right to compensation in accordance with applicable laws and
I certify that animals and/or materials listed above are properly identified and are eligible for indemnity and regulations. I hereby agree that the appraised value of animals and/or materials shown herein is in accordance with all applicable laws and
and I hereby expressly waive any claim I may have to compensation for animals and/or materials identified in this claim above the
animals and/or materials requiring appraisals are appraised individually unless all animals or materials in a regulations
value at which such animals and/or materials are appraised as shown on this claim. I further agree to the destruction of said animals and/or
group are of equal value.
materials.
27. NAME AND SIGNATURE OF GOVERNMENT APPRAISER OR
REPRESENTATIVE

28. TITLE

30. SIGNATURE OF OWNER-CLAIMANT OR AUTHORIZED REPRESENTATIVE IN
ITEMS 7 OR 8
32. DATE SIGNED

29. NAME AND SIGNATURE OF SPECIAL EXPERT APPRAISER

31. TITLE OF CLAIMANT

33. IF MORTAGED, FEDERAL INDEMNITY CHECK WILL BE DRAWN IN FAVOR OF MORTGAGOR
AND SHOULD BE MAILED TO:
OWNER-MORTGAGOR (Item 7)
MORTGAGEE (Item 7)

STATE CERTIFICATION: I certify the amount in Item 25 as due from the State Agency is correct and 34.a. NAME AND SIGNATURE OF MORTGAGEE OR AUTHORIZED REPRESENTATIVE
each such amount has been or will be paid the Owner-Claimant.
35. NAME AND SIGNATURE

36. TITLE

34.b. MORTGAGEE MAILING ADDRESS

37. STATE AGENCY

38. DATE

34.c. CITY

APPROVED

39. FOR $

VS FORM 1-23 (APR 2002)

40. ALLOTMENT NO.

41. BY NAME AND SIGNATURE

34.d. STATE

42. TITLE

34.e. ZIP CODE

43. DATE

44. PAGE ___ OF ___