Broodmare Leave of Absence

PENNSYLVANIA BROODMARE DOMICILE IN FOAL BROODMARE LEAVE OF ABSENCE FORM An in-foal broodmare for which a Pennsylvania Broodmare Domicile report has previously been filed with PHBA may be granted a LEAVE OF ABSENCE when consigned to a public sale in another state. Such a mare may be removed from Pennsylvania fourteen (14) days prior to the commencement of the sale, and in the event the mare is not sold, she must be returned to Pennsylvania within fourteen (14) days of the conclusion of the sale in order not to effect her in-state residency status for the foaling season in question. Should this occur, the owner of the broodmare must file the LEAVE OF ABSENCE form below to within seven days of the mare’s return to Pennsylvania to ensure the broodmare’s previously established in-state residency status is not jeopardized.

IN FOAL BROODMARE INFORMATION

Broodmare Name(Required)

Year Foaled(Required)

In Foal To(Required)

Sire Name(Required)

Dam Name(Required)

Foaling Date(Required)

Farm at which originally domiciled(Required)

Farm Phone(Required)

Sale Company(Required)

Hip No.

Date of Sale(Required)

Departure from PA Date(Required)

Return to PA Date(Required)

Farm to which mare was returned(Required)

Farm Owner(Required)

First Last

Return Farm Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Farm Phone(Required)

Broodmare Owner Name(Required)

First Last

Owner Phone(Required)

Owner Email(Required)

Name of person who completed this form(Required)

Date(Required)