VS 1-23 A Indemnity Worksheet - Owner/Company

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

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 0579-0208, 0579-0305, and 0579-0101. The time
required to complete this information collection 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 collection of information.

INDEMNITY WORKSHEET-OWNER/COMPANY
FARM NAME

APHIS PREMISE ID

CONTRACT GROWER NAME

FORM APPROVED
OMB NO.
0579-0208,
0579-0305,
0579-0101

FSA FARM ID

FARM ADDRESS

CONTRACT GROWER ADDRESS

COMPANY ADDRESS

TYPE OF FARM
COMPANY-OWNED FARM

CONTRACT-GROWER FARM

AUTHORIZED REPRESENTATIVE

TYPE OF BIRD
CB
FLOCK
IDENTIFIER

NO.

CBB

NO. OF BIRDS

TC (f)

DATE PLACED

TB(f)

TC (m)
DATE
DIAGNOSED

DATE
DEPOPULATED

DISPOSAL L,
I, C, CM

TB(m)
AGE AT
DEPOPULATION

LAY

NO.
DEPOPULATED

C/D DATE

COMPENSATION
VALUE

A
B
C
D
COMPANY REPRESENTATIVE

DATE

COMPENSATION FOR BIRDS

A

B

C

D

Value from Compenstion Plan ($ per Bird)
(X) Number of birds depopulated
(X) Value of birds (fair market value)
(=) Total compensation for birds available (50% fair market value)
(-) Compensation to grower from USDA (to be made whole)
(-) Slaughter value (if controlled marketing)
= Net compensation for birds to owners/company per flock
Net compensation to owner/company for flocks on farm
DISPOSAL COMPENSATION RATES ($/BIRD)
Disposal methods

Broilers/Table Egg Layers

$0

$0

$0.40

$1.60

$0.50

$2.00

Controlled slaughter
Incineration
Landfill

Turkeys

COMPENSATION FOR DISPOSAL COSTS
Number of birds depopulated
(X) Per bird disposal compensation (See rates above)
(=) Total compensation to owner for destruction a nd disposal
TOTAL COMPANY COMPENSATIONS
Net compensation to owners/company for birds
(+) Compensation to owner/company for destruction and depopulation
(=) Total compensation to owner/company
SIGNATURE

DATE

WITNESSED BY
NAME OF GOVERNMENT REPRESENTATIVE

VS FORM 1-23A (NOV 2002)

SIGNATURE

DATE

TOTAL