Form APHIS-7077 Summary of Alleged Violations

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 for this information collection is 0579-0056. The time required to complete this information collection is estimated to average.5 hours per recordkeeper, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved 0579-0056 EXP.: XX/XXXX

This report is required by regulation 9 CFR 11). Failure to provide information can result in criminal penalty(s) of up to $3,000 fine or imprisonment for one year or both (15 U.S.C. 1825).

United States Department of Agriculture Animal and Plant Health Inspection Service

Summary of Alleged Violations (Horse Protection Act)

1. EVENT (“X” one) SHOW SALE

NOTE FOR NARRATIVE CONTINUATION OF ANY ITEM, USE BLOCK 23. Cite Item Number Referred to.

2. Event Name and Address (Include street, city, state, and ZIP Code)

3. Event Manager Name and Address (Include street, city, state, and ZIP Code)

4. DATE AND APPROXIMATE TIME OF EVENT

5. SHOW RING (Circle as appropriate) Indoors, Outdoors, Dry, Wet, Muddy, Cold, Warm, Hot, Raining, Other (Specify)

6. INSPECTING DQP NAME(S)

(1)

7. DQP CERTIFIED ORGANIZATION

(2)

(Name)

(3)

(Street)

(4)

(State) (ZIP Code)

(5)

8. NAME OF PERSON (CUSTODIAN) PRESENTING HORSE FOR INSPECTION:

9. NAME OF PERSON WHO PAID ENTRY FEE

10. COPY OF ENTRY SHEET ENCLOSED YES NO

11. TRAINER NAME AND ADDRESS (Include street, city, state, and ZIP Code)

12. NAME AND ADDRESS OF PERSON(S) RESPONSIBLE FOR TRANSPORTATION

13. NAME AND ADDRESS OF PERSON(S) THAT ENTERED HORSE

14. OWNER NAME AND ADDRESS (Include street, city, state, and ZIP Code) “X” if minor – Give name and address of parent or guardian on reverse.

15. RIDER NAME AND ADDRESS (Include street, city, state, and ZIP Code) “X” if minor – Give name and address of parent or guardian on reverse.

16. NAME OF HORSE AND REGISTRATION NUMBER

17. WAS HORSE TYED YES NO PLACE:

EXCUSED: YES NO BY WHOM:

18. COLOR AND SPECIAL MARKING (Specify)

19. SEX

20. AGE

21. CLASS NUMBER

22. EXHIBITION NUMBER

23. ADDITONAL DECLARATIONS:

24. ITEMS 1 THROUGH 22 COMPLETED BY:

PLEASE SEE REVERSE SIDE FOR VMO TESTING

APHIS FORM 7077 OCT 2009

NOTE FOR NARRATIVE CONTINUATION OF ANY ITEM, USE BLOCK 36. Cite Item Number Referred to.

25. ACTION DEVICES (11.2(b)): CHAINS ROLLERS OTHER Overweight Strikes Coronet Yes No Weight LEFT leg device: Weight RIGHT Leg device: Weighed by:

26. PAD BAND MEASUREMENT (11.2(b) (13)): Right: Left:

27. HEEL/TOE MEASUREMENT: Left-Heel: Left-Toe: Right-Heel: Right-Toe:

Measured by:

Measured by:

28. PADS IN COMPLIANCE YES NO (Specify)

29. PROHIBITED SUBSTANCE (11.2 (c)): YES NO (If yes, explain)

30. IS HORSE SORE? YES NO (If yes, explain) (See item 8)

31. IS THIS HORSE IN VIOLATION OF THE SCAR RULE? (11.3) (See item 20 above) YES NO

32. THERMOGRAPHY NORMAL NOT NORMAL

33. HOOFTESTER NORMAL NOT NORMAL

34. DIGITAL RADIOGRAPHY NORMAL NOT NORMAL

35. ILLUSTRATE WHERE THIS HORSE IS SORE – (Lesions, Pain, Open Wounds, Blood, etc.,)

FRONT VIEW BACK VIEW LEFT FOOT RIGHT FOOT Medial Lateral Medial Lateral

36. Additional Declarations and/or Violations:

37. PHYSICAL EXAMINATION BY USDA VETERINARIAN(S) (Signature)

APHIS 7077 REVERSE

OCT 2009