Form VS 9-13 VS 9-13 Appraisal and Indemnity Request for HPAI-Affected Premis

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.

United States Department of Agriculture
Animal and Plant Health Inspection Service
Veterinary Services
Premises ID where birds are located:

OMB Approved
0579-XXXX
Exp.: XX/XXXX

Appraisal and Indemnity Request for HPAI-Affected Premises
Using Contract Growers

Address where birds are located:

Name:

Contract Grower Information
Phone Number:

Email Address:

Poultry Owner Information
Phone Number:

Email Address:

Address:

Name:

Address:

The (State Official) and (APHIS Official) have determined that poultry on this premises are affected by HPAI and the poultry must be depopulated within
24 hours. Indemnity for destroyed poultry and eggs affected by HPAI will be based on their fair market value, as determined by the current USDA APHIS
indemnity calculators. In cases where the destroyed poultry and/or eggs were produced by a Contract Grower, the appraised value of the poultry and
eggs will be split between the Contract Grower and Poultry Owner based on this formula:
1.

Divide the value of the contract the Owner entered into with the Grower for the growing and care of the poultry or eggs (in dollars) by the
duration of the contract (i.e., number of days in the contract duration) as it was signed prior to the outbreak.

2.

Multiply this value by number of days between the date the Grower started to provide services for the destroyed poultry or eggs and the date
the poultry or eggs were destroyed. This is the maximum amount of Federal indemnity the Contract Grower is eligible to receive, if Federal
indemnity is approved for the destroyed birds or eggs.

3.

If the Grower has received any payment from the Owner under his/her contract prior to the date when the poultry or eggs are destroyed, then
the Federal indemnity the Contract Grower is eligible to receive will be reduced by this amount.

4.

If Federal indemnity is approved for the destroyed birds and/or eggs, the Poultry Owner will receive the difference between the total indemnity
shown on the VS Form 1-23, Appraisal and Indemnity Claim, and the total indemnity paid to the Contract Grower.

5.

In the event that determination of indemnity to a party with which the Poultry Owner of destroyed poultry or eggs has entered into a contract
for the growing or care of the poultry or eggs using the method described in 1-4 of this section is determined to be impractical or inappropriate,
APHIS may use any other method for split payments that the Administrator deems appropriate.

Initial 1-5 and sign below:
____ 1.

At the time of the outbreak, I had in place and was following a biosecurity plan to prevent the introduction of Avian Influenza.

____ 2.

I understand that the poultry on the premises must be depopulated in the most humane manner possible within 24 hours.

____ 3.

I will provide barn and mortality records that verify the current inventory of poultry and eggs on the premises, which includes the number,
age, and molt status (if applicable) of the birds and the total number of eggs that must be destroyed.

____ 4.

I agree to accept the fair market value of the birds as determined by the APHIS calculator and the division of the indemnity payment
between the Grower and Owner as described above.

____ 5.

I agree to provide APHIS with a copy of the current contract executed between the parties as well as any supporting documentation
deemed necessary by APHIS to determine the appropriate division of the indemnity payment. This includes any checks or statements
indicating partial payments or advances already paid in association with the destroyed birds or eggs.

Signature:

Printed Name:

Title:

Date:

VS FORM 9-13
JAN 2016

Check One:
Owner

Grower