VS 1-23A Indemnity Worksheet - Owner/Company

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

Attach this form to
VS Form 1-23
OMB Approved
0579-0007, 0065, 0101, 0146, 0189, and 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, 0065, 0101, 0146, 0189, and 0192. 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.

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

NO.

SPECIES

4

5

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

7

APPRAISAL

8

1

PAGE:

OF

3. PROPER NAME OF DISEASE IMVOLVED

CONTINUATION SHEET – INDEMNITY CLAIM FOR
ANIMALS DESTROYED
MATERIALS DESTROYED
APPRAISED

2.

VALUE
PER UNIT

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

10

11

$

WEIGHT
OR
NO.
UNITS

TOTAL APPRAISAL

GRADE
ANIMALS
OR
MATERIALS
13

12

SALVAGE
(From
VS 1-24)

DIFFERENCE

AMOUNT DUE FROM

PUREBRED
ANIMALS

UNITED
STATES
15

14

16

STATE
AGENCY

17

18

$

$

$

$

$

$

$

$

$

$

$

$

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9
10
11
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13
14
15
16
17
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VS Form 1-23A
MAY 2009

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

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