VS 1-23A Continuation Sheet Idemnity Claim Form

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, 579-0101, 0579-0208, and 0579-0305. The time required to complete this information collection is estimated to average .50 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 0579-0047, 0579-0101, 0579-0208, and 0579-0305

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

INDEMNITY WORKSHEET OWNER/COMPANY

FARM NAME

APHIS PREMISE ID

CONTRACT GROWER NAME

FSA FARM ID

FARM ADDRESS

CONTRACT GROWER ADDRESS

COMPANY ADDRESS

TYPE OF FARM COMPANY-OWNED FARM CONTRACT-GROWER FARM

AUTHORIZED REPRESENTATIVE

Type of TTYPE OF BirD CB CBB TC (f) TC (m) TB (f) TB (m) LAY

FLOCK IDENTIFIER

NO.

NO. OF BIRDS

DATE PLACED

DATE DIAGNOSED

DATE DEPOPULATED

DISPOSAL, L, I, C, CM

AGE AT DEPOPULATION

NO. DEPOPULATED

C/D DATE

COMPENSATION VALUE

A

B

C

D

COMPANY REPRESENTATIVE

DATE

COMPENSATION FOR BIRDS

A

B

C

D

TOTAL

Value from Compensation Plan ($ Per Bird)

(X) Number of birds depopulated

(X) Value of birds (fair market value)

(=) Total compensation for birds available (50% fair market value)

(-) Compensation to grower from USDA (to be made whole)

(-) Slaughter value (if controlled marketing)

= Net compensation for birds to owners/company per flock

Net compensation to owner/company for flocks on farm

DISPOSAL COMPENSATION RATES ($/BIRD)

Disposal methods

Broilers/Table Egg Layers

Turkeys

Controlled slaughter

$ 0

$ 0

Incineration

$ 0.40

$ 1.60

Landfill

$ 0.50

$ 2.00

COMPENSATION FOR DISPOSAL COSTS

Number of birds depopulated

(X) Per bird disposal compensation (See rates above)

(=) Total compensation to owner for destruction and disposal

TOTAL COMPANY COMPENSATIONS

Net compensation to owner/company for birds

(+) Compensation to owner/company for destruction and depopulation

(=) Total compensation to owner/company

SIGNATURE

DATE

WITNESSED BY

NAME OF GOVERNMENT REPRESENTATIVE

SIGNATURE

DATE

VS 1-23A

APR 2009