OWNER STATEMENT - CHANGE OF OWNERSHIP

Current Owner's Premises Number 
    		 Number of Sheeps Date Animal or Animals received by Market/Dealership/Buyer
Date Animal or Animals Left Flock
   
Number of Goats Market/Dealer/Buyer ID Number or Name and Address

This Section needs to be completed at time of tagging and check-in

Current Owner
Last                                                 First                                 Initial
 		Flock of Origin*
Last                                                 First                                      Initial
Street Address
  		 Street Address

   
City                                                   State                           Zip


Telephone Number 		City                                                        State                       Zip

Telephone Number

List all animals in this shipment that are required to be officially identified

No. USDA Official Animal ID ID Type Other ID Flock of Birth (If Different Than Flock of Origin)

1

9E     9 I     9T

2   9E     9 I     9T    
3   9E     9 I     9T    
4   9E     9 I     9T    
5   9E     9 I     9T    
6   9E     9 I     9T    
7   9E     9 I     9T    
8   9E     9 I     9T    
9   9E     9 I     9T    
10   9E     9 I     9T    
11   9E     9 I     9T    
12   9E     9 I     9T    
13   9E     9 I     9T    

9 E - ear tag        9 I - Implant      9 T - Tattoo, brand or ear notch

Certification:
I CERTIFY THAT (Please check all that apply):
9The animals listed hereon are identified with official USDA ID assigned to the flock of origin by USDA unless identified with individual official ID and listed above or on an attachment.
9The animals are identified with a registered brand or ear notch pattern of the flock of origin, the animals were born and have resided in a commercial low risk flock throughout their lives, and the brand inspection certificate is attached.

Owner Signature __________________________________________     Date ________________________________

This document meets APHIS record-keeping requirements for animals identified prior to arrival at a concentration point.  Markets and dealers must keep and retain separate business records that indicate the purchases of the animals listed on this owner statement.  For any animal that requires a health certificate, a copy of the health certificate must also be retained.

COPIES CAN BE PRODUCED LOCALLY.