2019 Broodmare Domicile Report 2019 Broodmare Domicile Form - For Mares Foaling in 2019 2019 PA BROODMARE DOMICILE REPORT – FOR MARES FOALING IN 2019 Report to be Signed by Broodmare Owner - Please keep a copy for your records to confirm completion MANDATORY - MUST File by December 1, 2018, or within 14 days of Broodmare's Arrival in PA FOAL REGISTRATION CRITERIA - A Thoroughbred foal born in the state of Pennsylvania in 2019 and registered as such with The Jockey Club is eligible for Pennsylvania-Bred registration with the Pennsylvania Horse Breeders Association if one of the following conditions is met: Owners Email* Enter Email Confirm Email 2019 BMBR Form filled onlineQualification*(1) The dam of the foal resided continuously in Pennsylvania on or before December 1, 2018, through foaling; or(2) The dam of the foal was purchased at a public sale after December 1, 2018, then brought into Pennsylvania within 14 days of the date of purchase, and resided in Pennsylvania through foaling. During the year of foaling (2019), the foal or its dam must spend at least 90 days in the state; or(3) The dam of the foal will be bred back in 2019 to a stallion standing in Pennsylvania which is registered with the Pennsylvania Horse Breeders Association as a Pennsylvania stallion, and reside in the state for at least sixty (60) consecutive days during which foaling occurred.Check the choice above under which the foal of the subject broodmare will qualify.BROODMARE INFORMATIONResident*Year-Round PA Resident MareOut of State MareBroodmare Name*Year Foaled*2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983Broodmare Sire*Broodmare Dam*PA Arrival Date* Anticipated Foaling Date* Stallion mare is in foal to:*State 2018 Covering Stallion Stood*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMexicoAlbertaBritish ColumbiaManitobaOntarioQuebecSaskatchewan2019 Covering StallionState 2019 covering stallion standsAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMexicoAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonBROODMARE OWNER INFORMATIONBroodmare owner or managing partner’s name* First Last Owners Phone*(999) 555-1212 10 digit phone number with area code.Farm or Stable NameNot RequiredOwner Address* Street Address City State / Province / Region ZIP / Postal Code SSN/TID Number Last 4 digits ONLY*Last four digits ONLY of Broodmare Owner’s Social Security Number or Federal Tax ID Number FARM INFORMATIONFarm Broomare Domiciled at:Farm NameFarm Owners Name* First Last Farm Phone*Farm Address* Street Address City State / Province / Region ZIP / Postal Code Farm Veterinarian* First Last Vet’s Phone*(999) 555-1212 10 digit phone number with area code.AFFIDAVIT OF DOMICILE BY BROODMARE OWNERChecking "I Agree" and filling in the below Captcha is equivalent to a signed printed form* I Agree I, the undersigned broodmare owner, certify all information provided in order for this foaling broodmare to be eligible for participation in the Pennsylvania Breeding Fund program. I assume full responsibility for all information regarding this broodmare, and agree that if the broodmare is determined to be ineligible based upon inaccurate, false, or fraudulent information: (1) the foal may be ineligible for registration as a Pennsylvania-Bred; (2) I may be forever denied the privilege of registering PA-Breds; (3) I may be forever denied the benefit of any and all breeder awards; and (4) any awards paid based upon the performance of an ineligible foal shall be returned in full by the recipient to the Pennsylvania Breeding Fund. Furthermore, I agree to promptly provide any additional information requested by the official registrar, PA Horse Breeders Association, to confirm information submitted with this broodmare domicile form. I understand that the statements herein are made subject to the penalties of 18 PA C. S. 4904 (relating to unsworn falsification to authorities).CaptchaPhoneThis field is for validation purposes and should be left unchanged.