VS 1-23 Appraisal and Indemnity Claim Form

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 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, 0579-0185, 0579-0189, 0579-0192, and 0579-0208. The time required to complete this information collection is estimated to average between .16 and 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.

OMB Approved 0579-0007, 0579-0047, 0579-0101, 0579-0185, 0579-0189, 0579-0192 and 0579-0208

SEE INSTRUCTIONS ON REVERSE OF PART 5. BE SURE TO ATTACH REGISTRATION CERTIFICATES YOU ARE MAKING 5 COPIES – PRESS HARD AND CONTINUATION SHEETS (VS FORM 1-23A).

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES APPRAISAL AND INDEMNITY CLAIM FOR ANIMALS DESTROYED MATERIALS DESTROYED

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

2. ALLOTMENT NO.

3. PAGE OF

4. DATES ANIMAL/MATERIALS DESTROYED

5. DATE OF CLEANING AND DISINFECTING

6. LEGAL NAME AND MAILING ADDRESS OR OWNER CLAIMANT (No. and Street, or R.F.D. No., City and ZIP Code) (Type or Print)

7. PROPER NAME OF DISEASE INVOLVED

8. IF JOINT OWNERSHIP, GIVE FULL NAME OF ALL OWNERS (If SAME as Item 6, so state) (Not necessary if a Corporation)

9. LOCATION OF PREMISES WHERE APPRAISAL MADE (if different from item 6)

L I N E

APPRAISED

IDENTIFICATION OR PAGE NO. OF VS FORM 1-23A (Animals-Reactor Tag No., of Breed, Age, Sex, Tag No., Tattoo, Brand or other; Materials -Lbs., Bu., Tons, Board Feet, etc.)

APPRAISAL

WEIGHT OR NO. UNITS

TOTAL APPRAISAL

SALVAGE (From VS 1-24)

DIFFERENCE

AMOUNT DUE FROM

NO.

SPECIES

VALUE PER UNIT

UNIT (Head, Lb., Tons, etc,)

GRADE ANIMALS OR MATERIALS

PUREBRED ANIMALS

UNITED STATES

STATE AGENCY

AGE

SEX

BREED

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

1

$

$

$

$

$

$

$

2

3

4

5

G RAND TOTALS (Basis for Payment) (Includes all attached VS Forms 1-23a)

$

$

$

$

$

$

25. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING VALUE OF ANIMALS AND/OR MATERIALS.

OWNER-CLAIMANT MORTGAGE CERTIFICATION

CERTIFICATION AND APPRAISAL CERTIFICATE

I certify that the animals and/or materials identified in this claim are (initials)_____________are not (initials) ________mortgaged. I further certify that I own or am authorized to represent the owner 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 the animals and/or materials identified in this claim. I fully understand my right to compensation in accordance with applicable laws and regulations. I hereby agree that the appraised value of animals and/or materials shown herein is in accordance with all applicable laws and regulations and I hereby expressly waive any claim I may have to compensation for animals and/or materials identified in this claim above the value at which such animals and/or materials are appraised as shown in this claim. I further agree to the destruction of said animals and/or materials.

I certify that animals and/or materials listed above are properly identified and are eligible for indemnity and animals and/or materials requiring appraisals are appraised individually unless all animals or materials in a group are of equal value.

26. SIGNATURE OF GOVERNMENT APPRAISER OR REP.

27. TITLE

30. SIGNATURE OF OWNER-CLAIMANT OR AUTHORIZED REPRESENTATIVE IN ITEMS 6 OR 8

31. DATE SIGNED

28. SIGNATURE OF SPECIAL EXPERT APPRAISER

29. TITLE

32. TITLE OF CLAIMANT (Owner, co-owner, manager, Vice President, etc.)

STATE CERTIFICATE: I certify that the amount shown in item 24 as due from the State Agency is correct and that each such amount has been or will be paid the Owner-Claimant.

33. IF MORTGAGED - FEDERAL INDEMNITY CHECK WILL BE DRAWN IN FAVOR OF MORTGAGOR AND SHOULD BE MAILED TO (Check one) OWNER ( Mortgagor in item 6) MORTGAGEE (in item 34)

38. SIGNATURE

39. DATE

34. NAME AND ADDRESS OF MORTGAGEE (Include ZIP Code)

35. SIGNATURE OF MORTGAGEE OR AUTHORIZED REPRESENTATIVE IN ITEM 34

40. TITLE

41. STATE AGENCY

36. TITLE (Signed by Auth. Representative)

37. DATE

A PPROVED

42. FOR $

43. BY (SIGNATURE)

44. TITLE

45. DATE

VS FORM 1-23 Approved by the Comptroller Gen., U.S. (in lieu of SF-1034)

APR 2009

INSTRUCTIONS

Prepare separate claims for each disease. DO NOT include mortgaged and nonmortgaged items in the same claim. All items are self-explanatory, except as follows:

2.	To be completed by VS District or Area Office, or the Appraisal Section of the READEO.		25.	Source of Printing Data. 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. or ____________doz; daily rate of gain of __________lbs. in official test; preconditioned; team mascot; rare species or mutation; check endangered species list – talks; racing; proven breeder; pedigreed breeding flock; primary breeding flock; multiplier flock; etc.
3. 5.	Complete in all cases even when only one page is involved. 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, an entry such as “Not Required” or “Open Range, No C&D” should be inserted.
10.	Report number of animals or units. Explain in item 25 if obtained by other than actual count.		26-27.	Signature and title of the regulatory representative completing claim and/or making the appraisal.
			28-29.	Signature and title of a special expert appraiser whenever one is used to make the appraisal.
			30.	Legal signature of owner-claimant. Must agree with items 6 or 8. NOTE: The applicable entry in the owner-claimant mortgage certification must be initialed by owner-claimant prior to signature. The claim must be signed prior to the destruction of animals and/or materials or reasons to the contrary documented and approved.
11.	Identify species, e.g., cattle, sheep, pheasant, chickens, etc.
15.	For animals, report tags, brands, tattoos, etc. When indicated use a description, e.g., (pheasant) “golden,” (parrot) “Brazilian, trained and talking,” etc. For materials, any description which will identify the item, e.g., “wood feed bunk.”
16.	Price per head, per cwt., per board foot, each, etc.		33-37.	To be completed when animals are mortgaged. Separate claims for mortgaged and nonmortgaged animals should be prepared
19.	Record value for the units described in this line.		38-41.	This section must be signed and completed by an authorized State or other local cooperating agency official indicating the name of the State or agency and the official title of the representative if State indemnity will be paid.
20.	Record the value of animals claimed as being purebred and registered, recorded or otherwise entered in an Association or Society book, and meeting program requirements for “Registered” animals. Canceled Registration certificates must be filed with the claim at the applicable office in item 2.
21.	To be obtained from VS Form 1-24 when animal has been salvaged and salvage value is used in the calculation of indemnity.
			42-45.	Whenever all information necessary to substantiate every element of the claim has been obtained, 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.
23-24.	Complete in accordance with specific instructions for the disease involved (at State or VS Office).

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VS 1-23 (Reverse Part 5)

Form Copy Designations:

Part 1-Accounting Copy

Part 2-VS Station copy

Part 3-VS Station Copy

Part 4-State Office Copy

Part 5-Suspense Copy