VS 1-23A Continuation Sheet - Indemnity Claim for Animal Destroye

See instructions on reverse of VS Form 1-23, Part 5

Attach this form to
VS Form 1-23
OMB Approved
0579-0007, 0579-0047, 0579-0101, and 0579-0192

YOU ARE MAKING 5 COPIES – PRESS HARD

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)

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, and 0579-0192. The time required to complete this information collection is estimated to average .5-2 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

1. LEGAL NAME AND MAILING ADDRESS OF OWNER-CLAIMANT (No.
and Street, or R.F.D. No., City and ZIP Code (Type or print)

LINE

APPRAISED
NO.

SPECIES

4

5

MATERIALS DESTROYED

7

OF

SERVICES PROVIDED

IDENTIFICATION
(Animals-Reactor Tag No. or Breed, Age, Sex, Tag No., Tattoo, Brand or other,
Materials-Lbs., Bu., Tons, Board Feet, etc.)
9
AGE
SEX
BREED
6

PAGE:

3. PROPER NAME OF DISEASE IMVOLVED

CONTINUATION SHEET – INDEMNITY CLAIM FOR

ANIMALS DESTROYED

2.

APPRAISAL

8

1

$

VALUE
PER UNIT

UNIT
(Head, Lb.,
Tons, etc.)

10

11

WEIGHT
OR
NO.
UNITS

12

TOTAL APPRAISAL

$

GRADE
ANIMALS
OR
MATERIALS
13

PUREBRED
ANIMALS

$

14

SALVAGE
(From
VS 1-24)

DIFFERENCE

AMOUNT DUE FROM

UNITED
STATES

$

15

$

16

$

17

STATE
AGENCY

$

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

VS Form 1-23A
MAY 2009

←

Subtotals (Carry Forward to Page 1, VS Form 1-23)

→

$

$

$

$

$

$

18

Privacy Act Notice
Veterinary Services – Brucellosis Information System and Brucellosis Recording and Reporting System
Authority: 21 U.S.C. 111, 112, 114, 114a-1, 115, 120, 121, 125, 134a-134f and title 9, Code of Federal Regulations, part 51 and
part 78.
Purpose and Routine Uses:
Routine uses of records maintained in the system, including categories of users and the purposes of such uses:
1)
2)
3)
4)
5)
6)
7)

Detecting the foci of infection to reduce the rate of spread of infection to new herds;
Evaluating brucellosis program activities of State, Federal, and contractual personnel;
Preparing mailing labels and preaddressed forms to enhance field activities;
Evaluating program effectiveness;
Detecting factors of epidemiologic importance in containing or eliminating foci of infected herds;
Assuring that brucellosis indemnities are promptly and properly paid;
Notification of livestock owners with the animals at high risk of exposure to brucellosis because of livestock movements or
an outbreak of disease or presence of quarantined premises in a community;
8) Referral to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of investigating or
prosecuting a violation of law concerning animal disease control and eradication, or of enforcing or implementing a
statute, rule, regulation, or order issued pursuant thereto, of any record within this system when information available
indicates a violation or potential violation of law concerning animal disease control and eradication, whether civil, criminal,
or regulatory in nature, and either arising by general statute or particular program statute, or by rule, regulation, or court
order issued pursuant thereto;
9) Litigation by the Department of Justice when the agency, or any component thereof, or any employee of the agency in his
or her official capacity, or any employee of the agency in his or her individual capacity where the Department of Justice
has agreed to represent the employee, or the United States, where the agency determines that litigation is likely to affect
the agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such
records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation; provided,
however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of
the information contained in the records that is compatible with the purpose for which the records were collected;
10) Use in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the
agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the
agency in his or her individual capacity where the agency has agreed to represent the employee, or the United States,
where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation
or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the
litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use
of the information contained in the records that is compatible with the purpose for which the records were collected; and
11) Response to a request from a congressional office from the record of an individual made at the request of that individual.
To certain Federal and State animal health officials to conduct, analyze, and report on the progress of animal disease
control or surveillance programs.

Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede brucellosis
eradication activities.