Please complete this form.

If you need a receipt for tax purposes for donated mileage, print out and retain a copy of this form before you submit it.

Date of Transport *

Name of Transporter *

Street Address *

City *

State * AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI

Zip *

E-mail Address: *

Dog’s Name *

Transported From *

Transported To *

Total Miles Driven *

Miles to be Reimbursed

Miles to be Donated

Comments (optional)

Verification Code:

Enter Verification Code: *

* Required