VS 1-27 Permit for Movement of Restricted Animals

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 0579-0047, 0579-0101, 0579-0127, 0579-0185, 0579-0234,
0579-0338, and 0579-XXXX. The time required to complete this information collection is estimated to average .16 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.
This permit identifies restricted animals moved for quarantine/slaughter purposes. The information is needed to identify disease infected/exposed animals
that are moved to specific locations in order to control and prevent spread of the disease (9 CFR 71 through 85).

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

OMB Approved
0579-0047, 0579-0101,
0579-0127, 0579-0185,
0579-0234, 0579-0338, and
0579-XXXX

See reverse side for additional information.

NO.
5. STATE WHERE ISSUED

PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS
USE A SEPARATE FORM FOR EACH SPECIES
1. NAME AND ADDRESS OF SHIPPER OR CONSIGNOR (Include ZIP Code)

6. MOVEMENT TO BE

INTERSTATE

INTRASTATE

QUARANTINE

SLAUGHTER

7. MOVEMENT FOR

2. CONSIGNEE (Destination Name and Address, include ZIP Code)

8. DISEASE

9. STATUS OF ANIMALS
No.
Reactor

3. MOVED FROM (Name and Location of Premise if other than item 1 above)

10. STATUS OF HERD OF ORIGIN

4. NAME AND ADDRESS OF OWNER AT TIME CONDITION DIAGNOSED

12. NO. ANIMALS IN THIS SHIPMENT

No.
Exposed

No. Other
(Specify)

11. STATUS OF AREA OF ORIGIN

13. SPECIES (One only)

14. TRANSPORTATION VEHICLE LICENSE NO. OR OTHER IDENTIFICATION NO.
15. SEAL NO.

16. VEHICLE REQUIRED TO BE CLEANED AND
DISINFECTED AT DESTINATION
YES

VALID ONLY FOR ABOVE DESTINATION

NO

(If yes, items 32, 33, and 34 are applicable)
COMPLETE
EAR TAG NO.

BREED

SEX

DISEASE
BRAND

17. ANIMALS TO BE MOVED
OTHER IDENTIFICATION
COMPLETE
(Complete No.)
EAR TAG NO.

BREED

SEX

DISEASE
BRAND

OTHER IDENTIFICATION
(Complete No.)

I certify that I have inspected the animals described on this permit and find them eligible to move in accordance with the requirements of State and Federal regulations.
18. SIGNATURE OF INSPECTOR
19. DATE ISSUED
20. TIME ISSUED
VOID AFTER
21. DATE
22. TIME
WARNING TO OWNER, SHIPPER, AND TRUCKER - LIVESTOCK MUST BE DELIVERED TO CONSIGNEE WITHOUT DIVERSION.
I understand that it is a violation of Federal law to move the animals identified herein interstate except in accordance with the provisions of applicable Federal regulations. I also
understand that such animals must comply with existing State laws and regulations governing movement of livestock and poultry. I have arranged or will arrange for a copy of
this permit to accompany the interstate shipment and be delivered with the above described animals.
23. SIGNATURE OF OWNER OF SHIPPER
24. TITLE
25. DATE SIGNED
OWNER

SHIPPER

I certify that the animals described on this permit were received and slaughtered/quarantined in accordance with the requirements of the State and Federal regulations on the
date indicated in item 29.
26. PLACE ANIMALS RECEIVED
27. DATE ANIMALS ARRIVED
28. NO. ANIMALS RECEIVED
29. DATE SLAUGHTERED/QUARANTINED
30. DATE AND TIME
SEALS BROKEN

VS FORM 1-27
JUL 2011

31. AUTHORIZED SIGNATURE

32. DATE CLEANED
AND DISINFECTED
(if required)
Previous edition may be used.

33. SIGNATURE OF INSPECTOR

34. DATE SIGNED