VS 1-23A Indemnity Worksheet - Owner/Company

See instructions on reverse of VS Form 1-23, Part 5							YOU ARE MAKING 5 COPIES – PRESS HARD						Attach this form to VS Form 1-23
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 Part 51)													OMB Approved 0579-0007, 0579-0047, 0579-0101, 0579-0208, and 0579-0305
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 numbers for this information collection are 0579-0007, 0579-0047, 0579-0101, 0579-0288, and 0579-0305. The time required to complete this information collection is estimated to average .083 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.
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES								1. LEGAL NAME AND MAILING ADDRESS OF OWNER-CLAIMANT (No. and Street, or R.F.D. No., City and ZIP Code (Type or print)						2. PAGE: OF
CONTINUATION SHEET – INDEMNITY CLAIM FOR ANIMALS DESTROYED MATERIALS DESTROYED														3. PROPER NAME OF DISEASE IMVOLVED
LINE	APPRAISED		IDENTIFICATION (Animals-Reactor Tag No. or Breed, Age, Sex, Tag No., Tattoo, Brand or other, Materials-Lbs., Bu., Tons, Board Feet, etc.)					APPRAISAL		WEIGHT OR NO. UNITS 12	TOTAL APPRAISAL			SALVAGE (From VS 1-24) 15	DIFFER- ENCE 16	AMOUNT DUE FROM
	NO. 4	SPECIES 5	AGE 6	SEX 7	BREED 8	9		VALUE PER UNIT 10	UNIT (Head, Lb., Tons, etc.) 11		GRADE ANIMALS OR MATERIALS 13	PUREBRED ANIMALS 14				UNITED STATES 17	STATE AGENCY 18
1								$			$	$		$	$	$	$
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		← Subtotals (Carry Forward to Page 1, VS Form 1-23) →									$	$		$	$	$	$

VS Form 1-23A

MAY 2009