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L sheet(s) if necessary. See reverse side for additional instructions. 1. Submit To Appropriate Federal Agency: 2. Name, Address of claimant and claimant s personal representative, if any. (See instructions on reverse.) (Number, Street, City, State and Zip Code) USDA, APHIS, FMD, BCT, CLAIMS BUTLER SQUARE WEST 100 N. 6th Street, Suite 510C Minneapolis, MN 55403 3. TYPE OF EMPLOYMENT 9 MILITARY 9 CIVILIAN 4. DATE OF BIRTH FORM APPROVED OMB NO. 1105-0008 5. MARITAL STATUS 6. DATE AND DAY.

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