CITY OF ESTHERVILLE

ANIMAL ORDINANCE VIOLATION & IMPOUNDMENT REPORT

 

Date:          Time:    A.M.     P.M. 

Description Of Animal:  

Collar/Tag Information: 

Describe Any Apparent Injuries: 

Location Of Pick Up: 

Impounded for:     Running At Large        Bite               Delivered To Kennel By:  

Owner’s Name:   Address:  Phone: 

Owner Notified By:   Phone        In Person          Mail                                                 Date 


 

FOR BITE OR VICIOUS ANIMAL  -  TO BE COMPLETED BY POLICE

Victim’s Name:   Address:  

Part Of Body Bitten:        Medical Care?      Yes                 No   

Proof Of Animal’s Rabies Shot?      Yes       No         Initials  X                                     

If No Sign Of Rabies, Release Animal On:  ______________________________________________

VICIOUS - HOLD UNTIL FURTHER NOTICE:                                       Police Chief  X                                                  

Owner Notified:   Date:  Hearing Date:  ____________  Disposal Date:  ___________


BILLING INFORMATION

            Impoundment Penalty  (If Running At Large - $25.00)                                                          $                     

            Board Bill ________ Days @ $5.00/Day (Minimum $5.00 Fee)                                         $                     

            Other Costs (Explain):  _____________________________                                                                     

TO BE PAID TO CITY FINANCE OFFICE:  Received by  _________ Date  _________            $                     

(Above charges apply to animals released to owner from the Estherville Impound facility)

Authorized for Release to the owner by:      X                                                                                 Date:                         

Authorized for Release to the Humane Society by:            X                                                         Date:                         

HSNWI notified to pick up animal by            Phone                          Fax                                        Date:                         

Animal picked up by HSNWI and delivered to their animal shelter                                               Date:                         

RETURN THIS FORM TO THE COMMUNITY DEVELOPMENT OFFICE