Note: This Form Should Be Customized for the Town Or Agency. This Form Was Adapted From

Note: This form should be customized for the town or agency. This form was adapted from a form provided by the ASPCA. It would need modifying for livestock.

Town or Agency Heading

Animal Surrender Form

Seizure Date: ______Case #: ______Officer’s Name: ______Badge Number: ______

Animal Information

Total number of animals: ______

1. Species: ______Breed:______Sex: ______S/N: __ Age:______Color: ______

Animal ID#:______Rabies Tag No/Hospital:______License #/town:______

Has the animal bitten anyone? Date of bite: ______

2. Species: ______Breed:______Sex: ______S/N: __ Age:______Color: ______

Animal ID#:______Rabies Tag No/Hospital:______License #/town:______

Has the animal bitten anyone? Yes____ No ______Date of bite: ______

3. Species: ______Breed:______Sex: ______S/N: __ Age:______Color: ______

Animal ID#:______Rabies Tag No/Hospital:______License #/town:______

Has the animal bitten anyone? Yes____ No ______Date of bite: ______

More spaces or a separate sheet for more animals

OWNER/AGENT INFORMATION

Name:______Address: ______

City/Town: ______Zip: ______Phone:______

RELINQUISHING RECEIPT FOR ANIMALS SURRENDERED TO Town/Agency BY OWNER

 I acknowledge that my signature on this receipt relinquishes all claims of ownership of the animal(s) described above. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suites, or otherwise against The TOWN/AGENCY with respect to this animal(s). I understand that The TOWN/AGENCY will not return this animal to me, once left in its care, under any circumstances, unless otherwise approved by The TOWN/AGENCY. I am also aware that the animal(s) may be humanely euthanized if behavioral and/or medical problems render this animal(s) unsuitable for adoption.

 I acknowledge that my signature on this receipt grants permission to The TOWN/AGENCY, or its Agent to enter and remove any and all animals within address described above. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future rights, claims, suits, or otherwise against The TOWN/AGENCY with respect to this animal(s).I hereby agree to release, indemnify and hold harmless The TOWN/AGENCY, its past, present, and future officers, directors, agents and employees from and against any and all liability, claims, suits, actions, judgments, costs, fees, including reasonable attorney fees and damages caused by and/or arising out of and/or in connection with this animal(s).

Owner/Agent Signature:______Date:______

Note: If the animals were taken to a humane agency or other business for disposition, the animal inventory should be relisted with ID #’s date and whether released for adoption, treatment and/or euthanasia. There may need to be more than one agency listed.

DISPOSITION

The following animals were hereby released to Agents of Agency or business:
Date