U.S. DEPARTMENT OF AGRICULTURE 

 ANIMAL AND PLANT HEALTH INSPECTION SERVICE 



OWNER/SHIPPER CERTIFICATE 



FITNESS TO TRAVEL TO A SLAUGHTER FACILITY 



(CONTINUATION SHEET) 



(Please type or print In Ink) 



According to the Paperwork Reduction Act of 1995, no persons 

 are required to respond to a collection of information unless it 

 displays a valid 0MB control number The valid 0MB control 

 number for this information collection is 0579-0160, The time 

 required to complete this infonnation collection is estimated to 

 average 5 min. per response, including the lime for reviewing 

 instructions, searching existing data sources, gathering and 

 maintaining the data needed, and completing and reviewing the 

 collection of information. 



FORM 



APPROVED 



0MB NO. 



0579-0160 





TAG 

 PREFIX 



Tag 

 NO. 



COLOR DESCRIPTION 



BREEDHTPE 



SEX 



BRANDS 

 Tattoos, etc. 



REMARKS 



Include 

 precondition 





Bay 



Grey 



BIk. 



Pinto 



Chestn 



Other 



TB 



QT 



Draft 



Pony 



Other 



Mare 



Stal 



Geld 



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I HEREBY AUTHORIZE THE CFIA TO DISCLOSE THIS DOCUMENT AND THE INFORMATION IN IT AS COMPLETED BY THE CFIA TO THE USDA FALSIFICATION 

 OF THIS FORM OR KNOWINGLY USING A FALSIFIED FORM IS A CRIMINAL OFFENSE AND MAY RESULT IN A FINE OF NOT MORE THAN $10,000 OR 

 IMPRISONMENT FOR NOT MORE THAN 5 YEARS OR BOTH (18 U S.C. SECTION 1001). 



SIGNATURE OF OWNER/SHIPPER(l certify that the information contained In this fonn is tnje and con-ect to the best of my knowledge.) 



VSFORM 10-13A 

 (SEP 2002) 



PAGE 



OF 



16-35 



