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Sample agreement for surrendering animals to animal control or humane organization Case# _______________________________________ Date ______________________________ Law Enforcement Agency: ____________________________________________________________________ Employee’s Name ____________________________________ I.d.# ______________________________ Owner Surrendered _________________________ Abandoned _______________________ Animal Information Select One Of Two Alternative Options For Identifying Animals And Check Option Used �� OPTION 1: Species: ____________ Breed ______________________ Sex _____________ Age _________________ Color _____________________ License # ___________________ Rabies Tag # _____________________ Location ___________________________________________________________________________________ Species: ____________ Breed ______________________ Sex _____________ Age _________________ Color _____________________ License # ___________________ Rabies Tag # _____________________ Location ___________________________________________________________________________________ Attach additional sheets if necessary and check here �� if attached �� OPTION 2: All _____ Total Number Of Animals Individually Identified On The Attached List. Owner’s Name _____________________________________________________________________________ Address ____________________________________________________________________________________ ____________________________________________________________________________________________ Home Phone # _____________________________ Work/Cell # __________________________________ Driver’s License No. (Or Other Identification) __________________________________________________ SURRENDER ACKNOWLEDGEMENT I certify that I legally own the animal(s) identified above (including on any attached lists or sheets) and that no other person has any rights or interests in those animal(s). I acknowledge that my signature on this receipt relinquishes all claims of ownership of those animal(s). Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suits, or otherwise against the above named Law Enforcement Agency with respect to those animal(s). I understand that above named Law Enforcement Agency will not return those animal(s) to me, once left in its care, under any circumstances, unless otherwise approved by the above named Law Enforcement Agency. I am also aware that those animal(s) may be humanely euthanized if behavioral and/or medical problems render those animal(s) unsuitable for adoption I hereby agree to release, indemnify and hold harmless the above named Law Enforcement Agency, its past, present, and future officers, directors, agents, employees and volunteers from and against any and all liability, claims, suits, actions, judgments, costs, fees, including any and all attorneys fees and damages caused by and/or arising out of and/or in connection with such animal(s). Owner/Agent Signature ___________________________________________ Date ______________________ Appendix IV 96 The Humane Society of the United States


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