VS 1-27 Permit for Movement of Restricted Animals

Clear 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
OMB APPROVED
it displays a valid OMB control number. The valid OMB control numbers for this information collection are 0579-0047, 0579-0065, 0579-0101, 0579-0127, 0579-0146,
0579-0047, 0065, 0101,
0579-0338, and 0579-0393. The time required to complete this information collection is estimated to average between .16 hours and 2 hours. These times include time
0127, 0146, 0338, and 0393
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
This permit identifies restricted animals moved for quarantine/slaughter purposes. The information is needed to identify disease infected/exposed animals
See reverse side for additional information.
that are moved to specific locations in order to control and prevent spread of the disease (9 CFR 71 through 85).

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

NO.
5. STATE WHERE ISSUED

PERMIT FOR MOVEMENT OF RESTRICTED ANIMALS
USE A SEPARATE FORM FOR EACH SPECIES
1. NAME AND ADDRESS OF SHIPPER OR CONSIGNOR (Include ZIP Code)

6. MOVEMENT TO BE

INTERSTATE

INTRASTATE

QUARANTINE

SLAUGHTER

7. MOVEMENT FOR

2. CONSIGNEE (Destination Name and Address, include ZIP Code)

8. DISEASE

9. STATUS OF ANIMALS
No.
Reactor

3. MOVED FROM (Name and Location of Premise if other than item 1 above)

10. STATUS OF HERD OF ORIGIN

4. NAME AND ADDRESS OF OWNER AT TIME CONDITION DIAGNOSED

12. NO. ANIMALS IN THIS SHIPMENT

No.
Exposed

No. Other
(Specify)

11. STATUS OF AREA OF ORIGIN
13. SPECIES (One only)

14. TRANSPORTATION VEHICLE LICENSE NO. OR OTHER IDENTIFICATION NO.
15. SEAL NO.

16. VEHICLE REQUIRED TO BE CLEANED AND
DISINFECTED AT DESTINATION
YES

VALID ONLY FOR ABOVE DESTINATION

NO

(If yes, items 32, 33, and 34 are applicable)
COMPLETE
EAR TAG NO.

BREED

SEX

DISEASE
BRAND

17. ANIMALS TO BE MOVED
OTHER IDENTIFICATION
COMPLETE
(Complete No.)
EAR TAG NO.

BREED

SEX

DISEASE
BRAND

OTHER IDENTIFICATION
(Complete No.)

I certify that I have inspected the animals described on this permit and find them eligible to move in accordance with the requirements of State and Federal regulations.
18. SIGNATURE OF INSPECTOR
19. DATE ISSUED
20. TIME ISSUED
VOID AFTER
21. DATE
22. TIME
WARNING TO OWNER, SHIPPER, AND TRUCKER - LIVESTOCK MUST BE DELIVERED TO CONSIGNEE WITHOUT DIVERSION.
I understand that it is a violation of Federal law to move the animals identified herein interstate except in accordance with the provisions of applicable Federal regulations. I also
understand that such animals must comply with existing State laws and regulations governing movement of livestock and poultry. I have arranged or will arrange for a copy of
this permit to accompany the interstate shipment and be delivered with the above described animals.
23. SIGNATURE OF OWNER OF SHIPPER
24. TITLE
25. DATE SIGNED
OWNER

SHIPPER

I certify that the animals described on this permit were received and slaughtered/quarantined in accordance with the requirements of the State and Federal regulations on the
date indicated in item 29.
26. PLACE ANIMALS RECEIVED
27. DATE ANIMALS ARRIVED
28. NO. ANIMALS RECEIVED
29. DATE SLAUGHTERED/QUARANTINED
30. DATE AND TIME
SEALS BROKEN

VS FORM 1-27
JUL 2011

31. AUTHORIZED SIGNATURE

32. DATE CLEANED
AND DISINFECTED
(if required)
Previous edition may be used.

33. SIGNATURE OF INSPECTOR

34. DATE SIGNED

Privacy Act Statement
Authority:
The Honeybee Act, 7 U.S.C. 281-286; the Plant Protection Act, 7 U.S.C. 7701-7772 and 7781-7786; and the Animal Health
Protection Act, 7 U.S.C. 8301-8321.
Purpose:
This data will be used to enable persons wishing to move a regulated commodity into, from, or within the United States to apply for a
permit, pay permit application fees, check the status of a permit application, and view issued permits and other information online in
a secure manner.
Routine Uses:
In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act, records maintained in the system
may be disclosed outside USDA as follows:
1.
2.

3.
4.

5.

6.

7.

8.
9.

To the Department of Homeland Security's Customs and Border Protection agency, which inspects shipments that arrive
at United States ports for compliance with permit conditions;
To cooperative Federal, State, and local government officials, employees, or contractors, and other parties engaged to
assist in administering the program. Such contractors and other parties will be bound by the nondisclosure provisions of
the Privacy Act. This routine use assists the agency in carrying out the program, and thus is compatible with the purpose
for which the records are created and maintained;
To State government regulatory officials in the State of destination for review and comment;
To the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility of investigating or
prosecuting a violation of law or of enforcing, implementing, or complying with 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, 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;
To 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, in litigation, 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;
For 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;
To appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or
confidentiality of information in the system of records has been compromised; the agency has determined that as a result
of the suspected or confirmed compromise there is a risk of harm to economic or property interests, a risk of identity theft
or fraud, or a risk of harm to the security or integrity of this system or other systems or programs (whether maintained by
the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such
agencies, entities, and persons is reasonably necessary to assist in connection with the agency's efforts to respond to the
suspected or confirmed compromise and prevent, minimize, or remedy such harm;
To USDA contractors, partner agency employees or contractors, or private industry employed to identify patterns, trends
or anomalies indicative of fraud, waste, or abuse; and
To the National Archives and Records Administration or to the General Services Administration for records management
activities conducted under 44 U.S.C. 2904 and 2906.

Disclosure:
Furnishing this information is voluntary; however, failure to furnish this information may impede the ability to apply for a permit.