VS 5-13 Owner/Hauler Statement for Sheep and Goats

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 0579-0101 and 0579-0469. The time
required to complete this information collection is estimated to average 5 minutes 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

DATE ANIMALS
MOVED:

OWNER / HAULER STATEMENT
FOR SHEEP AND GOATS

NAME AND ADDRESS OF OWNER

OMB APPROVED
0579-0101, 0579-0469

NAME AND ADDRESS OF HAULER (If different then owner)

NAME

NAME

ADDRESS

ADDRESS

CITY/STATE/ZIP CODE

CITY/STATE/ZIP CODE

EMAIL (Optional)

EMAIL (Optional)

OTHER CONTACT (Optional)

OTHER CONTACT (Optional)

TYPE OF MOVEMENT
Check one of the movement types below, if none apply an owner/hauler statement is not required.

NOTE: An Interstate Certificate of Veterinary Inspection is required rather than an owner/hauler statement to cross a state line with a sexually intact sheep or goat that is not in slaughter
channels and is not moving to a federally approved livestock market or to another premise of same flock

To a livestock market for sale as feeder or slaughter animals

To an individual for personal slaughter

To a federally approved livestock market with sheep or goats that don’t
have official eartags

To an instate livestock market with sheep or goats that don’t have
official eartags

To another instate site to have official ID applied

To another premises of the same flock out-of-state

To a slaughter establishment

To a terminal feedlot

Other, please explain: _______________________________________________________

GROUP LOT ID NUMBER
Scrapie Flock ID based group/lot ID: flock ID-MMDDYY sequence number
Example: MD123456-061216-2

PIN/LID based group/lot ID: PIN/LID MMDDYY sequence number
Example: 004T5670-612161-2

FOR SHEEP/GOATS MOVING WITHOUT OFFICIAL ID
If different from the owner, the name, address, and flock ID or PIN of the flock of origin. (not required for animals under 18 months of age in slaughter channels)

DECLARATION
NUMBER OF
ANIMALS

SPECIES

BREED

(If unknown: for sheep include face color,
for goat include type; milk, meat, fiber)

CLASS

(Cull ewes/does, replacement
ewes/does, feeder lambs/kids,
slaughter lambs/kids, etc.)

POINT OF ORIGIN (If different then owner)

NAME AND ADDRESS OF DESTINATION

NAME

NAME

ADDRESS

ADDRESS

CITY/STATE/ZIP CODE

CITY/STATE/ZIP CODE

PHONE

PHONE

EMAIL (Optional)

EMAIL (Optional)

OTHER CONTACT (Optional)

OTHER CONTACT (Optional)

OWNER/HAULER SIGNATURE

(I do hereby certify that the information stated above is correct and the livestock listed are properly classified.)

VS FORM 5-13
NOV 2018

COMMENTS

DATE