Form VS 9-12 VS 9-12 Grower Contract Worksheets - Layers

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 OMB control number for this information collection is 0579-XXXX. The time required to complete this information collection
is estimated to average .5 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.

OMB Approved
0579-XXXX
Exp.: XX/XXXX

United States Department of Agriculture
Animal and Plant Health Inspection Service
Veterinary Services
To be completed and signed by the Contract Grower and then signed by the Company.
A copy of the contract and additional documentation may be required to determine payment amounts.
Premises ID where birds are located:

Grower Contract Worksheet – Layers

Address where birds are located:

Contract Grower Name:

Name of Company that Owns the Birds:

For each age group of birds, provide the following information:
Date through
Average Daily
which eggs
Bird Placement
Barn or Flock Number
Egg
have been
Date
Production
reimbursed

Amount expected
for eggs
produced since
last payment

Process used to determine expected contract
payment (e.g., price per bird and average load
out numbers, flat rate, average of last flocks,
etc.)

Signatures
Contract Grower Signature:

Date:

Company Representative Signature:

Date:

Depopulation Start Date:

VS FORM 9-12
JAN 2016

To be completed by the USDA/State Case Manager
Depopulation Completion Date: