VS 1-23A Indemnity Worksheet - Owner/Company

Scrapie Flock Certification, Animal Identification, and Indemnification Procedures

VS 1-23A-work May 2009

Private Sector

OMB: 0579-0101

Document [doc]
Download: doc | pdf

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

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$



$

$

$

$

$

$

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Subtotals (Carry Forward to Page 1, VS Form 1-23)

$

$

$

$

$

$

VS Form 1-23A

MAY 2009

File Typeapplication/msword
File TitleSee instructions on reverse of VS Form 1-23, Part 5
AuthorKhbrown
Last Modified Bysmharris
File Modified2011-12-13
File Created2009-04-30

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