Disclosure Form for Animal Control and Animal Shelters - Illinois

This printable "Disclosure Form for Animal Control and Animal Shelters" is a document issued by the Illinois Department of Agriculture specifically for Illinois residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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Name (Animal Control or Animal Shelter)
Address
City, State, Zip
Telephone
AW License ID #
Disclosures
Date Received:
Owner Relinquish or Impoundment: _______________________________
Cage/Kennel Number: _________
Breed: ________________
Estimated Age: _______ Color: ______________
Date of Birth: _______________
Sex: M F NM SF
Spay/Neuter Date: _________________
Adoption Fee: $
Additional Fees: $ ______ $ _______
Microchip #:
This animal was returned by an adopter on
for the following reason: ___________________________________
____________________________________________________________________________________________________
Inoculations and treatments of this animal since the date received:
Vaccinations/Inoculations
Diagnostic Tests
Product
Date
Date
Results
Rabies
________________
___________
Fecal
___________
_______
K-9 Distemper/Parvo
________________
___________
Parvo
___________
_______
FVRCP
________________
___________
Heartworm ___________
_______
FELV
________________
___________
FELV/FIV ___________
_______
Bordetella
________________
___________
Other
___________
_______
____________
___________
_______
Other
________________
___________
_______________
__________
Dewormers/Medications
Dosage
Date
Date
Date
Date
Date
Date
Date
Date
Additional information may be included on a separate sheet.
Remarks:
____________________________________________________________________________________________________
A copy of our policy regarding warranties, refunds, or returns is available upon request. The Provisions of Adoption are non-transferable.
Acknowledgement of Disclosures
I hereby attest that all of the above information is true and correct to the best of my knowledge.
________________________
_____________
(Shelter/AC) Staff:
Print Name
Signature
Date
I hereby attest that this disclosure was posted on or near the cage of the dog or cat for adoption and that I have read all the
disclosures. I further understand that I am entitled to keep a signed copy of this disclosure.
_______________________
Adopter:
Print Name
Signature
Date
Original: Animal Shelter/Animal Control
Copy: Adopter
Name (Animal Control or Animal Shelter)
Address
City, State, Zip
Telephone
AW License ID #
Disclosures
Date Received:
Owner Relinquish or Impoundment: _______________________________
Cage/Kennel Number: _________
Breed: ________________
Estimated Age: _______ Color: ______________
Date of Birth: _______________
Sex: M F NM SF
Spay/Neuter Date: _________________
Adoption Fee: $
Additional Fees: $ ______ $ _______
Microchip #:
This animal was returned by an adopter on
for the following reason: ___________________________________
____________________________________________________________________________________________________
Inoculations and treatments of this animal since the date received:
Vaccinations/Inoculations
Diagnostic Tests
Product
Date
Date
Results
Rabies
________________
___________
Fecal
___________
_______
K-9 Distemper/Parvo
________________
___________
Parvo
___________
_______
FVRCP
________________
___________
Heartworm ___________
_______
FELV
________________
___________
FELV/FIV ___________
_______
Bordetella
________________
___________
Other
___________
_______
____________
___________
_______
Other
________________
___________
_______________
__________
Dewormers/Medications
Dosage
Date
Date
Date
Date
Date
Date
Date
Date
Additional information may be included on a separate sheet.
Remarks:
____________________________________________________________________________________________________
A copy of our policy regarding warranties, refunds, or returns is available upon request. The Provisions of Adoption are non-transferable.
Acknowledgement of Disclosures
I hereby attest that all of the above information is true and correct to the best of my knowledge.
________________________
_____________
(Shelter/AC) Staff:
Print Name
Signature
Date
I hereby attest that this disclosure was posted on or near the cage of the dog or cat for adoption and that I have read all the
disclosures. I further understand that I am entitled to keep a signed copy of this disclosure.
_______________________
Adopter:
Print Name
Signature
Date
Original: Animal Shelter/Animal Control
Copy: Adopter

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