Form VS 1-23 VS 1-23 Appraisal and Indemnity Claim for Aniamls Destroyed/Mate

This information is required to be completed for the 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
OMB Approved
appraisal of animals, for which indemnity is
collection of information unless it displays a valid OMB control number. The valid OMB control numbers for these information collections are
0579-0007, 0579-0047, 0579-0101,
claimed. No monies or other benefits may be paid
0579-0007, 0579-0047, 0579-0101, 0579-0137, 0579-0146, 0579-0185, 0579-0189, and 0579-0192. The time required to complete this
0579-0137, 0579-0146, 0579-0185,
out unless this report is completed and filed as
information collection is estimated to average between .16 and 40 hours per response, including the time for reviewing instructions, searching
0579-0189, and 0579-0192
authorized under (9 CFR 51).
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
UNITED STATES DEPARTMENT OF AGRICULTURE
1. VS PROGRAM DISEASE NAME
2. PREMISES IDENTIFICATION NUMBER
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
3. HERD/FLOCK IDENTIFICATION NUMBER
4. HERD/FLOCK DISEASE STATUS

APPRAISAL AND INDEMNITY CLAIM FOR
ANIMALS DESTROYED

5. DATE ANIMALS/MATERIALS DESTROYED

MATERIALS DESTROYED

6. DATE OF CLEANING AND DISINFECTING

7.a. OWNER-CLAIMANT LEGAL NAME

9.a. PREMISES WHERE APPRAISAL WAS MADE (If different from Item 7)

7.b. OWNER-CLAIMANT MAILING ADDRESS (Number and street, or RFD)

9.b. PREMISES ADDRESS (Number and street, or RFD)

7.c. CITY

7.d. STATE

7.e. ZIP CODE

9.c. CITY

9.d. STATE

8. IF JOINT OWNERSHIP, GIVE FULL NAME OF ALL OWNERS (If same as Item 7.a., so state)

10. COUNTY

APPRAISED
L
I
N
E

11. DESCRIPTION/IDENTIFICATION/PAGE
NUMBER OF VS FORM 1-23A (Description of
Materials or Animal-reactor Tag Number,
Animal ID Number, Tattoo, Tag, or Brand)

12.
SPEC
IES

APPRAISAL

13.

14.
AGE

SEX

15.

16.

BREED

GRADE
PUREBRED/
MATERIALS

9.e. ZIP CODE

17.
UNIT
(head, lb,
ton, etc.)

18.
NUMBER
UNITS/WEIGHT

TOTAL APPRAISAL
19.
VALUE PER
UNIT

20.

21.
TOTAL
APPRAISAL

AMOUNT DUE FROM

22.

SALVAGE
VS FORM 1-24

DIFFERENCE

23.
UNITED STATES

24.
STATE AGENCY

1
2
3
4
5
25. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING VALUE OF
ANIMALS AND/OR MATERIALS

GRAND TOTALS
(Basis for payment)

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

CERTIFICATION AND APPRAISAL CERTIFICATE
I certify that the animals and/or materials listed above are properly identified and are eligible for indemnity
and that animals and/or materials requiring appraisals are appraised individually unless all animals or
materials in a group are of equal value.
27. NAME AND SIGNATURE OF GOVERNMENT APPRAISER OR REPRESENTATIVE

28. TITLE

OWNER-CLAIMANT MORTGAGOR CERTIFICATION
I certify that the animals and/or materials identified in this claim are (initials) ______, are not (initials) ______, not applicable
______ (initials) mortgaged. I further certify that I own or am authorized to represent the owner, or am otherwise the claimant,
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 on this claim. I further agree to the destruction of said animals and/or materials.
30. SIGNATURE OF OWNER-CLAIMANT OR AUTHORIZED REPRESENTATIVE IN ITEMS 7 OR 8

29. NAME AND SIGNATURE OF SPECIAL EXPERT APPRAISER

32. DATE SIGNED

STATE CERTIFICATION: I certify the amount in Item 25 as due from the State Agency is correct and
each such amount has been or will be paid to the Owner-Claimant.

34.a. NAME AND SIGNATURE OF MORTGAGEE OR AUTHORIZED REPRESENTATIVE

35. NAME AND SIGNATURE

36. TITLE

34.b. MORTGAGEE MAILING ADDRESS

37. STATE AGENCY

38. DATE

34.c. CITY

APPROVED

39. FOR $

40. ALLOTMENT NUMBER

41. BY NAME AND SIGNATURE

31. TITLE OF CLAIMANT

33. IF MORTAGED, FEDERAL INDEMNITY CHECK WILL BE DRAWN IN FAVOR OF MORTGAGOR
AND SHOULD BE MAILED TO:
OWNER-MORTGAGOR (Item 7)
MORTGAGEE (Item 7)

34.d. STATE

42. TITLE

34.e. ZIP CODE

43. DATE

44. PAGE
______ OF ______

VS FORM 1-23
SEP 2010

APPRAISAL AND INDEMNITY CLAIM INSTRUCTIONS
Prepare separate claims for each VS Program disease. Do not include mortgaged and non-mortgaged items in the same claim.
1.

List the proper name of the VS Program disease involved.

20.

Record the value for the units described, (Item(s) in 18 X price in Item 19).

2.

Premises Identification Number assigned by the State.

21.

Obtained from VS Form 1-24 when animal carcass has been salvaged.

3.

Herd/Flock Identification Number assigned by the State.

22.

Difference, self-explanatory.

4.

List the herd/flock disease status designated by the State or VS Area Office.

5.

Date(s) of slaughter or destruction of appraised animals or materials.

6.

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, insert an entry such as "Not Required"
or "Open Range," no "C&D" should be inserted.

7.

The proper legal name of the Owner-Claimant and the Owner-Claimant's complete
mailing address to include the building number and street, or RFD; city or town; State;
and ZIP code.

8.

If joint ownership, give full name of all owners (do not list the name in Item 7 again). This
is not necessary if owned by a corporation.

9.

Complete only when different then Item 7. The name and full address for the premises
where the appraisal was made.

10.

County in which the premises is located. If in multiple counties, insert the name of the
county where the premises' mailing address (Item 9) is located.

11.

For animals, report tag numbers, tattoos, electronic identification, or brands used, etc.
When indicated, use a description, e.g., "pheasant - golden"; parrot - Brazilian, trained
and talking", etc. For materials, any description that will reasonably identify the item,
e.g., "wood feed bunk."

12.
13 - 15.

23. - 24.
25.

Source of pricing data and/or special factors affecting the value of animals and/or
materials. 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. in official test; proven breeder; pedigreed breeding flock; primary
breeding flock; multiple flocks; etc.

26.

Date when materials/animals appraised and/or tagged and branded.

27 – 29.

Name, signature, and title of a special expert appraiser whenever one is used to make
the appraisal.

30.

Legal signature of the owner-claimant or authorized representative in Item 7 or 8. Must
agree with Item 7. NOTE: The applicable box in the "OWNER-CLAIMANT
MORTGAGOR CERTIFICATION" must be initialed prior to signature.

31.

Title of person signing as claimant, e.g., owner, partner, manager, Vice President, etc.

32.

Date signed, self-explanatory.

33 – 34.

To be completed when animals are mortgaged. Separate claims for mortgaged and
non-mortgaged animals should be prepared.

35 – 38.

This section must be completed by an authorized State or other local cooperating
agency official indicating the name of the State agency and official title.

39 – 43.

When all necessary information has been obtained, every element of the claim has
been substantiated 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.

Identify the species, e.g., cattle, sheep, bison, pig, chicken, parrot, etc.
Self-explanatory.

16.

Insert "M" for materials, "G" for grade animal, or "R" for registered purebred or otherwise
entered in an Association or Society book and meeting program requirements for
“registered animals."

17.

Describe unit, head, lb., cwt., ton, board foot, each, etc.

18.

Report the number of animals or units/weight.

19.

Price per head, lb., cwt., ton, board foot, each, etc.

VS FORM 1-23 (REVERSE PART 5)
SEP 2010

Complete in accordance with specific instructions for the disease involved. Obtained
from the State or VS office.

44.

Complete in all cases even when only one page is involved.

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