Form VS 1-23 VS 1-23 Appraisal and Indemnity Claim

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 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 these information collections are 0579-0047, 0101, 0579-0137, 0579-0185, 0579-0189, and 0579-0192. The time required to complete this information collection is estimated to average 1 hour 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 0579-0047, 0579-0101, 0579-0137, 0579-0185, 0579-0189, 0579-0192

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES APPRAISAL AND INDEMNITY CLAIM FOR ANIMALS DESTROYED MATERIALS DESTROYED

1. VS PROGRAM DISEASE NAME

2. PREMISES IDENTIFICATION NUMBER

3. HERD/FLOCK IDENTIFICATION NUMBER

4. HERD/FLOCK DISEASE STATUS

5. DATE ANIMALS/MATERIALS DESTROYED

6. DATE OF CLEANING AND DISINFECTING

7.a. OWNER-CLAIMANT LEGAL NAME

9.a. PREMISES WHERE APPRAISAL WAS MADE (If different from Item 7)

7.b. OWNER-CLAIMANT MAILING ADDRESS (Number and street, or RFD)

9.b. PREMISES ADDRESS (Number and street, or RFD)

7.c. CITY

7.d. STATE

7.e. ZIP CODE

9.c. CITY

9.d. STATE

9.e. ZIP CODE

8. IF JOINT OWNERSHIP, GIVE FULL NAME OF ALL OWNERS (If same as Item 7.a., so state)

10. COUNTY

APPRAISED

APPRAISAL

TOTAL APPRAISAL

AMOUNT DUE FROM

L I NE

11. DESCRIPTION/IDENTIFICATION/PAGE NUMBER OF VS FORM 1-23A (Description of Materials or Animal-reactor Tag Number, Animal ID Number, Tattoo, Tag, or Brand)

12. SPECIES

13. AGE

14. SEX

15. BREED

16. GRADE PUREBRED/ MATERIALS

17. UNIT (head, lb, ton, etc.)

18. NO. UNITS/ WEIGHT

19. VALUE PER UNIT

20. TOTAL APPRAISAL

21. SALVAGE VS FORM 1-24

22. DIFFERENCE

23. UNITED STATES

24. STATE AGENCY

1

2

3

4

5

25. SOURCE OF PRICING DATA AND/OR SPECIAL FACTORS AFFECTING VALUE OF ANIMALS AND/OR MATERIALS

GRAND TOTALS (Basis for payment)

26. DATE ANIMALS/MATERIALS APPRAISED AND/OR TAGGED AND BRANDED

OWNER-CLAIMANT MORTGAGOR CERTIFICATION I certify that the animals and/or materials identified in this claim are (initials) ____, are not (initials) _____, not applicable _____ (initials) mortgaged. 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 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 materials identified in this claim. I fully understand my right to compensation in accordance with applicable laws and regulations. I hereby agree that the appraised value of animals and/or materials shown herein is in accordance with all applicable laws and regulations and I hereby expressly 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.

CERTIFICATION AND APPRAISAL CERTIFICATE I certify that the animals and/or materials listed above are properly identified and are eligible for indemnity and that animals and/or materials requiring appraisals are appraised individually unless all animals or materials in a group are of equal value.

27. NAME AND SIGNATURE OF GOVERNMENT APPRAISER OR REPRESENTATIVE

28. TITLE

30. SIGNATURE OF OWNER-CLAIMANT OR AUTHORIZED REPRESENTATIVE IN ITEMS 7 OR 8

31. TITLE OF CLAIMANT

29. NAME AND SIGNATURE OF SPECIAL EXPERT APPRAISER

32. DATE SIGNED

33. IF MORTAGED, FEDERAL INDEMNITY CHECK WILL BE DRAWN IN FAVOR OF MORTGAGOR AND SHOULD BE MAILED TO: OWNER-MORTGAGOR (Item 7) MORTGAGEE (Item 7)

STATE CERTIFICATION: I certify the amount in Item 25 as due from the State Agency is correct and each such amount has been or will be paid to the Owner-Claimant.

34.a. NAME AND SIGNATURE OF MORTGAGEE OR AUTHORIZED REPRESENTATIVE

35. NAME AND SIGNATURE

36. TITLE

34.b. MORTGAGEE MAILING ADDRESS

37. STATE AGENCY

38. DATE

34.c. CITY

34.d. STATE

34.e. ZIP CODE

APPROVED

39. FOR $

40. ALLOTMENT NO.

41. BY NAME AND SIGNATURE

42. TITLE

43. DATE

44. PAGE ____ OF ____

VS FORM 1-23

SEP 2010

APPRAISAL AND INDEMNITY CLAIM INSTRUCTIONS

Prepare separate claims for each VS Program disease. Do not include mortgaged and non-mortgaged items in the same claim.

List the proper name of the VS Program disease involved. Premises Identification Number assigned by the State. Herd/Flock Identification Number assigned by the State. List the herd/flock disease status designated by the State or VS Area Office. Date(s) of slaughter or destruction of appraised animals or materials. The date cleaning and disinfection was actually accomplished as evidenced by a statement signed by the owner-claimant and on file, or a statement signed by a regulatory representative who supervised the cleaning and disinfection. When cleaning and disinfection is not required or is not indicated, insert an entry such as "Not Required" or "Open Range," no "C&D" should be inserted. The proper legal name of the Owner-Claimant and the Owner-Claimant's complete mailing address to include the building number and street, or RFD; city or town; State; and ZIP code. If joint ownership, give full name of all owners (do not list the name in Item 7 again). This is not necessary if owned by a corporation. Complete only when different then Item 7. The name and full address for the premises where the appraisal was made. County in which the premises is located. If in multiple counties, insert the name of the county where the premises' mailing address (Item 9) is located. For animals, report tag numbers, tattoos, electronic identification, or brands used, etc. When indicated, use a description, e.g., "pheasant - golden"; parrot - Brazilian, trained and talking", etc. For materials, any description that will reasonably identify the item, e.g., "wood feed bunk." Identify the species, e.g., cattle, sheep, bison, pig, chicken, parrot, etc. 13-15. Self-explanatory. Insert "M" for materials, "G" for grade animal, or "R" for registered purebred or otherwise entered in an Association or Society book and meeting program requirements for “registered animals." Describe unit, head, lb., cwt., ton, board foot, each, etc. Report the number of animals or units/weight. Price per head, lb., cwt., ton, board foot, each, etc.

Record the value for the units described, (Item(s) in 18 X price in Item 19). Obtained from VS Form 1-24 when animal carcass has been salvaged. Difference, self-explanatory. 23. & 24. Complete in accordance with specific instructions for the disease involved. Obtained from the State or VS office. Source of pricing data and/or special factors affecting the value of animals and/or materials. Whenever a value is established for an animal or for a unit of material, or for a group of animals or units of like class and value, a source of such value must be listed. This is especially important when the appraised item has an unusual value. Some sources or factors used for this purpose are: price at ___________________livestock market on (date) or price at a (named) local source for animals of like quality and purpose; proven sire; bill of sale; trained; trained to perform; production record of ________ lbs. in official test; proven breeder; pedigreed breeding flock; primary breeding flock; multiple flocks; etc. Date when materials/animals appraised and/or tagged and branded. 27-29. Name, signature, and title of a special expert appraiser whenever one is used to make the appraisal. Legal signature of the owner-claimant or authorized representative in Item 7 or 8. Must agree with Item 7. NOTE: The applicable box in the "OWNER-CLAIMANT MORTGAGOR CERTIFICATION" must be initialed prior to signature. Title of person signing as claimant, e.g., owner, partner, manager, Vice President, etc. Date signed, self-explanatory. 33-34. To be completed when animals are mortgaged. Separate claims for mortgaged and non-mortgaged animals should be prepared. 35-38. This section must be completed by an authorized State or other local cooperating agency official indicating the name of the State agency and official title. 39-43. When all necessary information has been obtained, every element of the claim has been substantiated and is filed with each claim, and every action has been completed, it should be recommended for payment by the signature of the official or acting official in charge. Completion of this section will imply certification as to the correctness of each claim, Including justifying statements in Item 25 and other substantiating documents in the station files. Complete in all cases even when only one page is involved.

VS FORM 1-23 (REVERSE PART 5)

SEP 2010