STATE OF WISCONSIN
Town of ________
________ County
I, the undersigned, chairperson of the Town of ________, ________ County, Wisconsin, certify that on the application of ________ ________, residing in the town, I viewed [
describe stray], taken up by ________ ________ as a stray, and appraise the stray to be worth the sum of $________. I further certify that the fee for this certificate is 50 cents and the charge for travel expenses is $________.
Dated this ______ day of ________, 20__.
[Signature of town chairperson]
