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NASHUA ~ MUNICIPAL IMPOUND CLAIM FORM for Police or ACO
Date: _ ee fj Time: 653 6 Police/ACO Control #
Officer name:
ANIMAL INFORMATION: SSH Running atlarge? _Y68 No
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| Bite Quarantine? Yes NE) When did bite occur?
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( provide owners info belo is known)
Other reason:
Is Animal on Hold? Yes No (If Yes, contact Officer —_ )
LOCATION (street address & city/town) of pick up: _/Z Liab Satie AF
Gender: Female . Male | Spayed Neutered
Breed: | a pee z De -
Color: Cape Pf
Other identifying featurés: J Co a
Collar: Ab. a a
License Tag #: } a tT AS Tie
OWNER INFORMATION:
LastName: bau
First Name: GOWN 2 NOC
Sireet Address: = "Monz0 Phad
Town/City: MOSAUG 7 ; Cf usar beafpheg age
State: Ni. ame en
Phone Number: (905 337 (2915 | & GAS. on ee
Owner's date of birth: uf [25 7/1989 RG
ls dog currently licensed? Yes Dog Licetise re wig
Rabies Expiration Date: La
ls a $25 cash bond required? YES ( NO
No dog, cat, or ferret shall be released or removed fr nement until the owner has provided proof that the
dog, cat, or ferret is currently vaccinated against rabies, and all applicable license, board, and care fees have
been paid. If the owner does not have proof that the dog, cat, or ferret is currently vaccinated against rabies, then the
owner may post a $25 cash bond to secure the release of the dog, cat, or ferret in order for the owner to obtain a rabies
vaccination for the dog, cat, or ferret. if, within 72 hours of the dog, cat, or ferret's release the owner provides proof of
obtaining a rabies vaccination for the dog, cat, or ferret, then the owner shail be refunded the full bond amount.
Payment of impoundment fees does not release the owner/keeper of responsibility for fines that may
be imposed by the District Court. This form releases the applicable city/town and the Humane Society
from all liability involving the impounded animal(s). .
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Owner/keeper Signature: me A ne Date_S, \ 2
Owner/keeper Printed Name: Baw 3A
Initials of HSFN staff releasing animal to owner:
MAKE A COPY OF THIS FORM AFTER THE FINAL DISPOSITION & GIVE TO ACO
mA fs Se anette nse WC OLLIUN & GIVE TO ACO
