Virginia Stallion Virginia Breeders Fund Application for Registration of a Virginia Thoroughbred Stallion

Fee Schedule (stallions must be registered annually with the Virginia Breeders Fund) VTA Member Fee Non-Member Fee

Annual Registration (by January 31 of the year standing in Virginia or within 30 $100 $200 days of entry into Virginia)

Annual Late Registration (after February 1 but before August 31 of the year $250 $350 standing in Virginia)

Registration Requirements

• Stallions must be registered ANNUALLY with the Virginia Breeders Fund • To be eligible for awards from the Virginia Breeders Fund, a stallion owner/lessee must submit this application to the Virginia Thoroughbred Association prior to the commencement of the breeding season of the year in which the stallion will be siring Virginia-bred or within thirty (30) days of the stallion’s entry into in the Commonwealth of Virginia if such entry is after the breeding season commences. • A copy of the stallion’s Jockey Club registration papers, clearly showing the front and transfer side of the document, must accompany this application.

PLEASE PRINT OR TYPE Jockey Club registered name of stallion:______Year foaled:______Jockey Club registration no.: ______Sire: ______Dam: ______Dam’s Sire: ______

Stallion/Owner Lease Information

W-9 forms will be required to be filed with VTA in order to collect any winnings $600.00 and above. Winners will be contacted and must return a completed W-9 before prize monies will be awarded.

PLEASE PRINT OR TYPE Stallion owner/lessee name:______Address: ______City:______State: ______Zip: ______Phone: ______Fax: ______Standing farm:______Address: ______City:______State: ______Zip: ______Phone: ______Fax: ______

Affidavit: I, the undersigned, hereby certify that, pursuant to the information given by me above, this thoroughbred is a thoroughbred stallion that covers , other than test mares, only in Virginia during the breeding season in which it sires a Virginia-bred Thoroughbred horse, or only during that part of the breeding season after entering Virginia. I certify that this horse is eligible for Virginia Thoroughbred Stallion registration and participation in the Virginia Breeders Fund. I assume full responsibility for the registration of this horse, and agree that if the horse is later proved to be ineligible based on false or fraudulent information provided by me; 1) the horse shall no longer be considered a Virginia Thoroughbred Stallion; 2) I may be forever denied the privilege of participating in the Virginia Breeders Fund incentive programs; 3) any awards paid based upon the performance of an ineligible horse shall be returned in fully by the recipient to the Virginia Breeders Fund; 4) I am subject to any and all civil and criminal penalties associated with providing fraudulent information under the laws of the State of Virginia.

All applications must be complete and accompanied by the appropriate registration fee or they will be returned. Please make checks payable to and submit registration application/fees to: The Virginia Breeders Fund, 250 West Main Street, Suite 100, , VA 22902 | (434) 977-3716 | (434) 979-2439 fax | www.vabred.org Owner’s Signature: ______Printed Name: ______Date: ______