VS 1-23 Appraisal and Indemnity Claim 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 valid OMB control numbers for these information collections are 0579-0007, 0579-0065, 0579-0101, 0579-0146, 0579-0189, and 0579-0192. The time required to complete this information collection is
estimated to average between .16 and 40 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

OMB APPROVED
0579-0007, 0579-0065, 0579-0101, 0579-0146, 05790189, and 0579-0192

APPRAISAL AND INDEMNITY CLAIM
ANIMALS DESTROYED

MATERIALS DESTROYED

SERVICES PROVIDED

This information is required to be completed for the appraisal of animals, materials, and/or services for which indemnity is claimed. No monies or other benefits may be paid out unless this report is completed and filed as authorized.

SECTION I - CLAIMANT INFORMATION
1. DISEASE NAME

6. PREMISES IDENTIFICATION NUMBER

11. CLAIMANT(S) LEGAL NAME (must match DUNS/SAMS information in Item 10)

2. HERD/FLOCK/GROUP IDENTIFICATION

7. PREMISES WHERE APPRAISAL WAS MADE (if different from Item 12; must match Item 6)

12. CLAIMANT MAILING ADDRESS (number and street, or RFD)

3. HERD/FLOCK/GROUP DISEASE STATUS

8. PREMISES ADDRESS (number and street, or RFD)

13a. CITY

4. DATE(S) ANIMALS/MATERIALS DESTROYED
AND/OR SERVICES PROVIDED

9a. CITY

9b. COUNTY

9c. STATE

9d. ZIP CODE

13b. COUNTY

10a. DUNS NUMBERS

10b. SAMS REGISTERED
YES

13d. ZIP CODE

14. CLAIMANT IS
OWNER

5. DATE OF CLEANING AND DISINFECTING

13c. STATE

CONTRACT GROWER

OTHER (specify)

15. IF JOINT OWNERSHIP, GIVE FULL NAMES OF ALL OWNERS (if same as Item 11, so state)
NO

SECTION II - APPRAISAL FOR ALL SPECIES EXCEPT AVIAN
A. ANIMALS APPRAISED
L 16.
I
N
E

B. APPRAISAL
20.
21.
22.
23.
BREED RELATED PAGE
UNIT
NUMBER OF
NUMBERS FOR (head, LB, UNITS/WEIGHT
VS FORM 1-23A ton, etc.)

C. TOTAL CLAIM

24a.
VALUE PER
UNIT

25.

1

$

$

2

$

3
4

DESCRIPTION/IDENTIFICATION
OF ANIMALS

17.
18.
19.
SPECIES AGE
SEX

5
24b. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING VALUE
OF ANIMALS (attach to this form)

D. AMOUNT DUE FROM
27.
DIFFERENCE

28.
29.
U.S. GOVT AGENCY

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

41.
DIFFERENCE

42.
43.
U.S. GOVT AGENCY

GRAND TOTALS
(basis for payment)

26.
TOTAL
APPRAISAL

SALVAGE
(VS Form 1-24)

OTHER

SECTION III - APPRAISAL FOR AVIAN SPECIES
A. BIRDS/EGGS APPRAISED
L 30.
I
N
E

32.
33.
AGE
SEX

B. APPRAISAL
34.
35.
36.
DAYS RELATED PAGE
UNIT
IN 2ND NUMBERS FOR
(head
LAY
VS FORM 1-23A or egg)

1

$

$

$

$

$

$

2

$

$

$

$

$

$

3

$

$

$

$

$

$

4

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

38b. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING VALUE
OF ANIMALS (attach to this form)

VS FORM 1-23
AUG 2018

GRAND TOTALS
(basis for payment)

Previous editions may be used.

40.

D. AMOUNT DUE FROM

39.

5

37.
NUMBER OF
UNITS/WEIGHT

C. TOTAL CLAIM

38a.
VALUE PER
UNIT

DESCRIPTION/IDENTIFICATION
OF ANIMALS
(barn and flock numbers)

31.
AVIAN
TYPE

TOTAL
APPRAISAL

SALVAGE
(VS Form 1-24)

OTHER

SECTION IV - APPRAISAL FOR PATHOGEN ELIMINATION
A. PROCESSED APPRAISED
44.
L
I
N
E

B. APPRAISAL
45.

DESCRIPTION OF PATHOGEN
ELIMINATION PROCESS

46.
UNIT
NUMBER OF
(gallons, hours,
UNITS, HOURS,
square foot, etc.)
OR WEIGHT

C. TOTAL CLAIM
47a.
48.
PRICE PER UNIT

49.
TOTAL
APPRAISAL

50.

DATE
REQUIREMENTS
MET FOR
FIRST
PAYMENT

51.
PAYMENT 1

52.

DATE
REQUIREMENTS
MET FOR
SECOND
PAYMENT

1

$

$

$

$

2

$

$

$

$

3

$

$

$

$

4

$

$

$

$

5

$

$

$

$

GRAND TOTALS
(basis for payment)

$

$

$

47b. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING
PRICING (attach to this form)

53.
PAYMENT 2

NOTES

SECTION V - APPRAISAL FOR MATERIALS DESTROYED AND SERVICES PROVIDED
A. MATERIALS/SERVICES APPRAISED
L 54.
I
DESCRIPTION OF MATERIALS
N
DESTROYED AND/OR SERVICES
E
PROVIDED

55.
ADDITIONAL
INFORMATION
ATTACHED?

B. APPRAISAL
56.

57.
UNIT
NUMBER OF
(gallons, hours,
UNITS, HOURS,
square foot, etc.)
OR WEIGHT

C. TOTAL CLAIM
58a.
59.
PRICE PER UNIT
APPRAISAL
SUBTOTAL

60.
SALVAGE
(VS Form 1-24)

61.
DIFFERENCE

62.
GRAND TOTAL

1

YES
NO

$

$

$

$

$

2

YES
NO

$

$

$

$

$

3

YES
NO

$

$

$

$

$

4

YES
NO

$

$

$

$

$

5

YES
NO

$

$

$

$

$

$

$

$

$

58b. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING
VALUE OF MATERIALS AND/OR SERVICES (attach to this form)

GRAND TOTALS
(basis for payment)

63.
NOTES

SECTION VI - CERTIFICATIONS
OWNER-CLAIMANT MORTGAGOR CERTIFICATION
I certify that the animals, materials, and/or services identified in this claim are mortgaged (check and initial one).

CERTIFICATION AND APPRAISAL CERTIFICATE
No _____ I certify that the animals and/or materials listed above are properly identified and are eligible for indemnity and that animals,
I further certify that I own or am authorized to represent the owner, or am otherwise the claimant, of the animals and/or materials identified in this services, and/or materials requiring appraisals are appraised individually unless all animals or materials in a group are of equal
claim. I make claim for all amounts due me in accordance with all applicable laws and regulations governing the payment for the animals and/or value.
Yes _____

materials identified in this claim. I fully understand my right to compensation in accordance with applicable laws and regulations. I hereby agree 69. DATE ANIMALS/MATERIALS APPRAISED AND/OR
that the appraised value of animals and/or materials shown herein is in accordance with all applicable laws and regulations and I hereby expressly TAGGED AND BRANDED
waive any claim I may have to compensation for animals and/or materials identified in this claim above the value at which such animals and/or
materials are appraised as shown on this claim. I further agree to the destruction of said animals and/or materials.

70. CALCULATOR AND/OR APPRAISAL METHOD USED

64. SIGNATURE OF CLAIMANT OR AUTHORIZED REPRESENTATIVE AS SHOWN IN ITEM 11

65. Date

71. NAME, TITLE, AND SIGNATURE OF GOV’T APPRAISER/REPRESENTATIVE

66. NAME AND SIGNATURE OF MORTGAGEE OR AUTHORIZED REPRESENTATIVE

67. Date

72. NAME, TITLE, AND SIGNATURE OF SPECIAL EXPERT APPRAISER

68d. ZIP CODE

STATE CERTIFICATION
I certify the amount in Item 29 as due from the State Agency is correct and each such amount has been or will be paid to the
Claimant.
73. NAME, TITLE, AND SIGNATURE OF STATE REPRESENTATIVE

68a. MORTGAGEE MAILING ADDRESS

68b. CITY

68c. STATE

76. IF MORTAGED, FEDERAL INDEMNITY PAYMENT WILL BE DRAWN IN FAVOR OF MORTGAGOR AND SHOULD BE MAILED TO:
OWNER-MORTGAGOR (Item 11)

APPROVED
VS FORM 1-23
MAR 2017

77. FOR $

74. STATE AGENCY

75. DATE

MORTGAGEE (Item 11)
78. ALLOTMENT NUMBER

79. BY NAME, TITLE, AND SIGNATURE OF APPROVAL AUTHORITY

Previous editions may be used.

80. DATE

81. PAGE
______ OF ______