TO:                 

Delaware Department of Agriculture
Pesticide Section
2320 S. DuPont Hwy.
Dover, DE 19901

1.

Date of pesticide application suspected of causing damage:

2.

Date of Loss (or discovery of damage):

3.

Pesticides used or product names:

4.

Claimant’s property or crop allegedly damaged (name crop, i.e. , ornamentals, pasture, animals, persons, etc.; and

if person, name, address and phone number of health professional involved):

5.

Symptoms or conditions observed:

6.

Is claim due to pesticide non-performance (failure to control insects, weeds or other pests)?

 Yes

 No

7.

If damage to growing crop, has 25% of crop been harvested?

 Yes

 No

8.

Who made the pesticide application (check one):

 Commercial Operator

 Farmer

Unknown

 Other (specify)

Name:

Address:

City, State, Zip:

Phone:

9.

Landowner (or renter) for whom pesticide was applied:

Name:

Address:

City, State, Zip:

Phone:

10.

Suspected cause or source of damage (mark all appropriate):

 Ground Application

 Air application

 Neighbor spraying

 Other

11.

Statement of facts concerning pesticide use and alleged damage:

Time of Day:

Weather:

Wind Direction:

Estimated Wind Speed:

Temperature:

12.

History of pesticides, fertilizers, and other chemicals used by you or the previous occupant on damaged site (attach

additional sheets if necessary):

13.

Have other investigators observed the damage?

 Yes

 No

Name:

Affiliation:

I hereby request that the Delaware Department of Agriculture investigate to determine the cause of the alleged damage and agree that Department of Agriculture personnel my have reasonable access to property which I own or control for purposes of inspecting the alleged damage and collection of samples.  I further agree that I will cooperate with the investigation and will make myself available as a witness in any legal action or administrative proceeding which may result.

Signature:

Date: