Form Dl-12r-Assessors Report Of Appraisal Of Damages To Domestic Animals Caused By Rabies
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2DL-12R (Rev. 10/02)
STATE OF NEW YORK
DEPARTMENT OF AGRICULTURE AND MARKETS
County of ________________________
Town of _____________________________
ASSESSOR’S REPORT OF APPRAISAL OF DAMAGES
TO DOMESTIC ANIMALS CAUSED BY RABIES
To__________________________________,
Treasurer, County of ____________________________________________
P.O.Address_____________________________________________________________ State of New York:
It is hereby reported that ________________________________________P.O.___________________________________________
Is the owner of domestic animals which died as the result of rabies on or about _____________________________, 20___________
Town
In the City of____________________________________________________; That discovery was made of such damage or loss on
_______________________________; Notice of claim was made to___________________________________________________
an assessor of the City in which the loss occurred on _________________________, 20_____________requesting that the amount of
damage be ascertained. The investigation and appraisal were made on ____________________________________, 20__________
1.
Was each animal’s head removed and sent to an approved laboratory?
_________
(Yes or No)
2.
Did you examine an official laboratory report for each animal?
_________
(Yes or No)
When? ____________________________________________
3.
Does laboratory report accompany this appraisal?
_________
(Yes or No)
If not, explain____________________________________________________
4.
Are you satisfied that the animal or animals died from rabies?
_________
(Yes or No)
5.
If answer to Item 4 is no, explain reason for disallowing claim:
_______________________________________________________________
6.
If purebred dairy cattle were appraised, did you examine registry papers?
_________
(Yes or No)
(If appraised at purebred value, reg. Certif., must accompany this report.)
7.
Are you satisfied that the animals were purebred and that the registry
_________
(Yes or No)
Certificates filed with this report cover the animals appraised?
AMOUNT OF DAMAGE DETERMINED BY ASSESSOR
AMOUNT
KIND OF ANIMAL
AGE
EAR-TAG NO.
REG. NO
ALLOWED
$
Total Allowed
$
STATE OF NEW YORK
)
SS.:
COUNTY OF ____________________)
____________________________________________________being duly sworn, say, that he is a qualified assessor of the town of
_________________________________________,and was called upon determine and fix the amount of damages alleged to have been
caused by rabies; that an investigation was made, and the facts set forth in this report relative to such investigation are true to the best of
his knowledge and belief.
Sworn to before me this ________________day
_______________________________________________
Assessor
of ___________________________, 20_________
APPROVED__________________________________________
County Treasurer
If claim is approved, County Treasurer must fill
or
Out and sign certificate on back and send to the
Commissioner immediately for his decision.
DISAPPROVED;________________________________________
County Treasurer
____________________________, 20__________
Month
Day
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