ADOPTION 911 / A Nonprofit 501(c)(3) Public Charity

Owner surrender form

I certify that I am the legal owner and represent all other owners of the

animal described below. I took physical possession of this animal on:

Date__________State:_________________________________________

I hereby relinquish all ownership rights to The Sweet Water Ranch Inc. Adoption 911 rescue program.

Owner’s Name (print):_________________________________________

Co Owner's name_____________________________________________

Address:____________________________________________________

City:___________________________________County:______________ State:__________________________________Zip:_________________

Home phone:___________________ Work phone:__________________

E-Mail address:_______________________________________________

Driver’s License Number:_______________________________________

Expiration date___________________State:_______________________

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Animal’s Barn Name: __________________________________________

Animal's Registered Name:______________________________________

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Approx Age:_________________

Equine / Canine / Feline / Other :________________________________

Breed:_____________________________________________________

Markings / Color:_____________________________________________

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Registered ID #______________________________________________

This animals temperament is: Very Gentle / Mild / Average

Has Some Issues / Hard to Handle / Wild or Feral / Other

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This animal is: Mare: Yes - no / Currently in Foal : yes - no

Gelding: yes - no / Stud: yes - no

Spayed : yes -no / Neutered : yes - no

Micro chipped : yes - no

Chip registered ID#_________________________________________

Has this animal hurt anyone, or been involved in an accident in the

past 60 days?Was it reported to an Animal Control Agency, Police Dept.

or any human or animal medical facility?. If you answered yes to any of these questions what date did this incident occur and to whom was

it reported to?

___________________________________________________________

Your reason for relinquishment:__________________________________

___________________________________________________________

Where did you originally obtain the animal? Past owner's info if possible.

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Your Vets name and phone number:______________________________

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I understand that I am surrendering my animal to The Sweet Water Ranch Inc./Adoption 911 program. If the animal is deemed un-adoptable by SWR Adoption 911 because of health issues or behavioral, I understand that it may be humanely euthanized. You agree to allow SWR Adoption 911 to talk with your Vet and release all health records regarding this animals health care program. I certify that I am the legal owner and I have no contractual obligation, verbal or written with any agency, organization, or individual concerning the surrender of said animal described herein. I understand that there will be a processing fee - donation due in conjunction with the surrender paperwork. Fees will be determined by each animals situation and condition at the time of surrender to SWR Adoption 911.

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Please Sign__________________________________________________

Owner's signature Date

Please Sign__________________________________________________

Co Owner's Signature Date

______________________________________________________

Approved by Candi C. Cooper Date

CEO / SWR Adoption 911

______________________________________________________

*This surrender form is not legally binding without the signature

of Candi C. Cooper CEO SWR Adoption 911.

*Please copy and complete this form, then send it by e-mail or fax.

adoption911@gmail.com

Fax (818) 992-6657

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*Please e-mail or scan the following and please submit with this form:

A photo of the animal to be surrendered. A photocopy of your drivers license and or a picture I.D. Any type of registration and or medical paperwork on this animal. If you are surrendering multiple animals, please use an additional form for each animal. Thank you.

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