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

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 0579-0065, 0579-0192, and 0579-XXXX. The time required to complete this
information collection is estimated to average .5 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
0579-0065, 0192,
and XXXX

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