HomeMy WebLinkAboutPet Adoption ApplicationCITY OF PALM DESERT
Animal Adoption Incentive Program
Reimbursement Request Form
PLEASE COMPLETE THIS SECTION
Name of Individual Requesting Reimbursement:
Telephone Number: Email Address (optional)
Palm Desert Address:
Mailing Address:
City: State: Zip Code:
I hereby certify that I am a City of Palm Desert resident.
Resident’s Signature: Date:
PROOF OF ELIGIBILITY OF RESIDENCY
A valid identification (i.e. driver’s license or state-issued ID card), documentation or receipts for the pet
adoption, plus one of the following:
Type of pet adopted: □ Dog □ Cat □ Other _____________
Date Reimbursement Request Form received: Animal ID#
Received by: Amount requested: $
Approved □ Denied □ (Due to residency requirements)
Authorized signature to approve reimbursement:
FOR OFFICIAL USE ONLY
□ Utility bill with your City of Palm Desert address
□ Property Tax Bill with your City of Palm Desert address
□ Your rental or lease agreement with utility bill showing City of Palm Desert address