See instructions on reverse of VS Form 1-23, Part 5 |
YOU ARE MAKING 5 COPIES – PRESS HARD |
Attach this form to VS Form 1-23 |
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This information is required to be completed for the appraisal of animals, for which indemnity is claimed. No monies or other benefits may be paid out unless this report is completed and filed as authorized under (9 CFR Part 51) |
OMB Approved 0579-0007, 0579-0047, 0579-0101, 0579-0208, and 0579-0305 |
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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 0579-0007, 0579-0047, 0579-0101, 0579-0288, and 0579-0305. The time required to complete this information collection is estimated to average .083 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. |
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UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES |
1. LEGAL NAME AND MAILING ADDRESS OF OWNER-CLAIMANT (No. and Street, or R.F.D. No., City and ZIP Code (Type or print) |
2. PAGE: OF |
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CONTINUATION SHEET – INDEMNITY CLAIM FOR ANIMALS DESTROYED MATERIALS DESTROYED |
3. PROPER NAME OF DISEASE IMVOLVED |
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LINE |
APPRAISED |
IDENTIFICATION (Animals-Reactor Tag No. or Breed, Age, Sex, Tag No., Tattoo, Brand or other, Materials-Lbs., Bu., Tons, Board Feet, etc.) |
APPRAISAL |
WEIGHT OR NO. UNITS
12 |
TOTAL APPRAISAL |
SALVAGE (From VS 1-24)
15 |
DIFFER- ENCE
16 |
AMOUNT DUE FROM |
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NO.
4 |
SPECIES
5 |
AGE
6 |
SEX
7 |
BREED
8 |
9 |
VALUE PER UNIT
10 |
UNIT (Head, Lb., Tons, etc.)
11 |
GRADE ANIMALS OR MATERIALS 13 |
PUREBRED ANIMALS
14 |
UNITED STATES
17 |
STATE AGENCY
18 |
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← Subtotals (Carry Forward to Page 1, VS Form 1-23) → |
$ |
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$ |
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VS Form 1-23A
MAY 2009
File Type | application/msword |
File Title | See instructions on reverse of VS Form 1-23, Part 5 |
Author | Khbrown |
Last Modified By | smharris |
File Modified | 2011-12-13 |
File Created | 2009-04-30 |