Breeders Fund Registration Form

2016 PENNSYLVANIA SIRE STAKES SUSTAINING PAYMENT FORM NOTE: PAYMENT TO P/M SIRE STAKES INCLUDES ELIGIBILITY TO STALLION SERIES

2 YR OLD 3 YR OLD ST ** 1 PAYMENT – MARCH 15, 2016 FINAL PAYMENT – MARCH 15, 2016 $150 Pari Mutuel division $500 Pari Mutuel division $ 25 Fair division FINAL PAYMENT – MAY 15, 2016 ND 2 PAYMENT – MAY 15, 2016 $100 Fair division $400 Pari Mutuel division $ 50 Fair division **Horses who make the March 15 payment(s) at 2 retain their eligibility to 3-year-old events even if not **Not making the March 15 2 yr old payment(s) causes making the 2YO May 15 payments, although they are automatic elimination from this stake at 2 & 3. then ineligible at 2 with no 2YO 5-15 payment(s).

OWNER/AGENT INFORMATION Name(s): Address: City: State: Zip Code: Telephone No: Email: HORSE INFORMATION (Please enter the horse’s previous name if there has been a name change.)

Name: Previous Name:

Reg. No: A Foal of (yr):

Gait (please circle): PACE TROT Sex (please circle): COLT FILLY GELDING

Sire: Dam: PAYMENT INFORMATION PARI MUTUEL DIVISION FAIR DIVISION □ Two year old 1st sustaining payment - $150 □ Two year old 1st sustaining payment - $25 □ Two year old 2nd sustaining payment - $400 □ Two year old 2nd sustaining payment - $50 □ Three year old sustaining payment - $500 □ Three year old sustaining payment - $100

All payments must be made in U.S. FUNDS.

Please note: Mail must be postmarked by the 15th of the payment month to be eligible for the program. Owners of stakes horses are ultimately responsible for timely payments.

MAKE CHECK PAYABLE TO: PENNSYLVANIA SIRE STAKES MAIL TO: PENNSYLVANIA SIRE STAKES FUND 2301 N. CAMERON ST. ROOM 301 HARRISBURG PA 17110 If you have any questions, please call 1-866-Win In PA/1-866-946-4672.

NO FURTHER NOTICES WILL BE SENT – CERTIFIED MAIL IS SUGGESTED

www.agriculture.state.pa.us