VS 1-26 Appraisal and Indemnity Request for Affected Premises Us

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 it
displays a valid OMB control number. The OMB control numbers for this information collection are 0579-0007, 0579-0047, 0579-0065, 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.

OMB APPROVED
0579-0007, 0047,
0065, and 0192

UNITED STATES DEPARTMENT OF AGRICULTURE
Appraisal
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
PREMISES ID WHERE ANIMALS/ANIMAL PRODUCTS ARE LOCATED:

and Indemnity Request for Affected Premises
Using Contract Growers

DISEASE:

PRESUMPTIVE POSITIVE DATE:

ADDRESS WHERE ANIMALS/ANIMAL PRODUCTS ARE LOCATED:

CONTRACT GROWER INFORMATION
NAME:

PHONE NUMBER:

EMAIL ADDRESS:

OWNER INFORMATION
PHONE NUMBER:

EMAIL ADDRESS:

ADDRESS:

NAME:

ADDRESS:

The State Official or Tribal Official and APHIS Official have determined that animals/animal products on this premises are affected with a disease.
Animals on this premises will be depopulated by State and/or APHIS and/or industry personnel; the State-Federal-Industry goal is to complete
depopulation within 24 hours of detection. Indemnity for destroyed animals/animal products affected by disease will be based on their fair market
value, as determined by the current USDA APHIS indemnity calculators.
In cases where the destroyed animals and/or animal products were produced by a Contract Grower, the appraised value of the animals and animal
products will be split between the Owner and Contract Grower based on the terms of the contract currently in place for the growing or care of the
affected animals and animal products.
In the event that determination of indemnity as described above is deemed to be impractical or inappropriate, APHIS may use any other method for
split payments that the Administrator deems appropriate.
If Federal indemnity is approved for the destroyed animals and animal products, the Animal Owner will receive the difference between the total
indemnity shown on the VS Form 1-23, Appraisal and Indemnity Claim, and the total indemnity paid to the Contract Grower.
I understand that I have the right to dispute the proposed split Federal indemnity payment by notifying the APHIS Administrator, in writing; the APHIS
Administrator has the final authority for determining Federal indemnity payments.
VS FORM 1-26
MAY 2016

Initial 1-5 and sign below:
____ 1.

At the time of the outbreak, I had in place and was following a biosecurity plan to prevent the introduction of Avian Influenza, if applicable

____ 2.

I understand that the animals/animal products on the premises must be promptly depopulated in the most humane manner possible.

____ 3.

I will provide records that verify the current inventory of animals/animal products on the premises that must be destroyed.

____ 4.

I agree to accept the fair market value of the animals/animal products, as determined by the APHIS calculator, according to the inventory
on the premises at the time this document is signed.

____ 5.

I agree to provide APHIS with a copy of the current contract executed between the parties as well as any supporting documentation
deemed necessary by APHIS to determine the appropriate division of the indemnity payment. This includes any checks or statements
indicating partial payments or advances already paid in association with the destroyed animals/animal products.

____ 6.

I understand that I must obtain a Dun and Bradstreet Data Universal Numbering System (DUNS) number and register in the Federal
System for Award Management (SAM) database to receive an indemnity payment from USDA APHIS.

Owner Signature:

Printed Name of Owner:

Owner Title:

Date:

Contract Grower Signature:

Printed Name of Contract Grower:

Contract Grower Title:

Date:

For Internal Use Only
Congressional District:

Additional Remarks:

VS FORM 1-26 (Reverse)
MAY 2016

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.