County Court District Court ____________________________________ County, Colorado Court Address: People of the State of Colorado v. COURT USE ONLY Defendant: _____________________________________________ Case Number: Division Courtroom NOTICE AND PAYMENT FOR COST OF CARE OF ANIMALS PURSUANT TO §18-9-202.5, C.R.S The purpose of this notice and payment is to provide for the cost of impoundment, care and provision of identified animal(s) in the custody of the impound agency for a period of at least 30 days, including the day on which the animal was taken into custody, pursuant to §18-9-202.5, C.R.S. Payment Type: Cash Certified Funds Payment Amount Determined by Impound Agency: $ _________________ Type of Animal(s): __________________________________________________ Number of Animals impounded: _________ (Note: Individual Animals must be identified on a separate document by name, brief description and/or other identifying characteristics). Payment is for a period of 30 days and commences on ___________________________ (date animal(s) was/were taken into custody). Payment is made By: __________________________________________ (Full Name of Party) ______________ (Date of Birth). ____ Owner/Custodian ____ Other Name of Impound Agency: ______________________________________ Telephone Number: ____________________ Address: _____________________________________________________________________________________________ By signing below, the Owner/Custodian affirms the following: I hereby acknowledge that by making this payment it may prevent the disposition of the identified animal(s) and will be used for the impoundment, care of and provision for said animal(s) for thirty days commencing on _______________________ (date). If however, in the opinion of a licensed veterinarian, an animal is experiencing extreme pain or suffering or is severely injured past recovery, severely disabled past recovery, or severely diseased past recovery, the animal may be euthanized without court order pursuant to §18-9-202.5(2)(c), C.R.S. I understand that the above payment must be filed within 10 days after impoundment, or in the alternative, I may request a hearing to determine (1) whether the costs set forth in this notice are fair and reasonable and necessary for the impoundment, care and provision of said animal(s); and/or (2) whether there was sufficient probable cause for the impoundment. If probable cause is found at the hearing, I will be responsible for filing the payment for costs at the hearing. I understand that failure to pay the impoundment, care and provision costs may result in a forfeiture of my ownership rights to the said animal(s). I further understand that at the end of the time for which expenses are covered by the payment, if I wish to prevent disposition of the animals(s), I shall file a new payment with the Court within ten (10) days prior to the previous payment’s expiration. Date: _____________________ ____________________________________________ Signature of Defendant Owner/Custodian ____________________________________________ Address ____________________________________________ City, State, Zip Code ____________________________________________ (Area Code) Telephone Number (home) ______________________________________________________________________________________________ Executed and acknowledged by the above-named in the presence of the undersigned. Date: __________________________ JDF 228 R9/12 __________________________________________ Clerk of Court/Deputy Clerk NOTICE and PAYMENT FOR COST OF CARE OF ANIMALS PURSUANT TO §18-9-202.5, C.R.S. American LegalNet, Inc. www.FormsWorkFlow.com