Please attach all copies of all documentation related to this puppy/dog to this form, including breeder papers, medical records, Kennel Club registry papers, legal documents, and anything pertaining to your complaint.

Today’s Date: _____________

Breeder Complaint Form Provided by The Humane Society of the United States Complainant Contact Information:

Full Name ______________________________________________________________

Address ______________________________________________________________

City ______________________________________ State ________Zip Code _______________

Daytime Phone Number ______________________________________________________________

Complete Email Address ______________________________________________________________

Breeder Contact Information

Breeder name ______________________________________________________________

Name Doing Business As (Name of Kennel/Facility) ______________________________________________________________

Street Address ________________________________________________________________________ City __________________________________________State _________Zip________

Phone Number ______________________________________________________________

Breeder email _____________________________________________________________

Website Address (If applicable) _______________________________________________________

How did the puppy come to your home? (Be specific: air shipped, picked up, driven, etc.) ___________________________________________________________________________________

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How did you hear of breeder? (Be specific: Internet (give address), newspaper (please identify paper and date), friend, sign, etc.)

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Is Breeder registered with a "kennel club": (American Kennel Club (AKC), United Kennel Club (UKC), Canadian Kennel Club (CKC), other? Yes No

Did the breeder provide you with registry papers for your pet? Yes No

Did the breeder provide you with medical records for your pet? Yes No

Did you sign a contract with the breeder? Yes No

Were you advised of any health guarantees on the puppy? Yes No

If yes, were they supplied in writing? Yes No

Were you advised of any protections afforded to you under state law should the puppy become ill? Yes No

Did you request to tour the breeder’s home/facility? Yes No

If yes, were you provided that tour? Yes No

Were there specific concerns you had when touring the facility? Areas you were refused access to? (Please explain)

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Pet Store Information (fill out only if animal was purchased at a retail store):

Name of Store Manager Sales Person who assisted you ________________________________________________________

Address City State Zip Code ________________________________________________________________________

Phone Number __________________________________cell phone ______________________________________

Website ________________________________________________________________________________________

Did puppy leave with you the day of purchase? ________________________________________________________________________

How did you hear of the pet store? (Be specific: Internet (give address), newspaper (please identify paper and date), friend, sign, etc.)

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Did the pet store provide you with transfer documents/breeder papers/other listing the name of the breeder/broker whom the puppy came from? Yes No

Did the pet store provide you with kennel club registry papers for your pet? Yes No

Did the pet store provide you with medical records for your pet? Yes No

Did you sign a contract with the pet store? Yes No

Were you advised of any health guarantees on the puppy? Yes No

If yes, were they supplied in writing? Yes No

Were you advised of any protections afforded to you under state law should the puppy become ill? Yes No

Does the pet store also sell exotic animals (fish, birds, rodents)? Yes No

Website Information (fill out only if animal was purchased off Internet): _______________________________________________________________________________________________________

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Name Doing Business As (Name of Kennel/Facility) ______________________________________________________

Street Address ________________________________________________________________________

Phone Number Website Address (If applicable) ___________________________________________________________

How did you learn of this specific website? ____________________________________________________________

How was puppy paid for? ________________________________________________________________________

How did the puppy come to your home? (Be specific: air shipped, picked up, driven, etc.) _______________________________________________________________________________________________________

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Was there an interview before you were allowed to purchase the puppy? Yes No

Did the breeder provide references? Yes No

If yes, did you contact those references? Yes No

Were you advised of any health guarantees on the puppy? Yes No

If yes, were they supplied in writing? Yes No

Animal Information: ________________________________________________________________________

Type of Animal________________________________________________________________________

Breed________________________________________________________________________

Age when obtained ________________________________________________________________________

Sex ________________________________________________________________________ Was the animal altered (spayed/neutered) by breeder or pet store? Yes No

Was the animal altered by you? Yes No

If yes, at what age? _______

Please describe the puppy’s condition upon arrival/pick up (Use back of page if needed):
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Were you advised of veterinary care the animal had received prior to purchase? Yes No

If yes, please explain:
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Note if information was received verbally or in writing (Be specific: Use the back of this page if necessary):
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How soon after purchase did you take the animal to a veterinarian to be examined? ______________________________

Was it your regular veterinarian or one referred to you by the pet shop/breeder? ________________________________

Were you required by the pet shop/breeder to use their veterinarian? Yes No

Was the vet visit for health exam/vaccinations or because of medical concerns? Please explain (Be specific):

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At what point did you first notice the animal may be suffering from medical problems? Please explain (Be specific):

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Is the animal currently living? Yes No

If no, please explain how he or she died (Be specific):

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How old was the animal at the age of death? ________ weeks/months/years

Were there any prior medical conditions that you were aware of upon purchasing the dog? Yes No

If yes, please explain (Be specific):
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Did your veterinarian issue a "Not Fit to Sell" certificate upon examining the animal? Yes No

Have you contacted any organizations, professionals, or others about your complaint, besides The Humane Society of the United States? Yes No

If yes, please list the agencies contacted:
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Have you contacted a lawyer? Yes No

If yes, please list lawyers contact information:
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Additional Description of Complaint (Be specific. Attach extra pages if necessary):
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Print Your Name ___________________________________________________

Signature __________________________________________________________ Date ___________

Please attach all documentation related to this puppy to this form, including breeder papers, medical records, Kennel Club registry papers, legal documents, and anything pertaining to your complaint. Once this form is complete, make six copies:

Send one copy to The Humane Society of the United States,
2100 L Street NW
Washington, DC 20037

(Please include a hard copy of all relevant documents, e.g. medical records, breeder papers, receipts, etc., with this complaint form.)

Send one copy to the Department of Agriculture for the state in which the breeder does business.
Send one copy each to the Attorney General of the state in which the breeder resides and in your state.
Send one copy to the Better Business Bureau.

Save one copy and all originals for your records.

Contact information for these above agencies should be available in your phone book (state agencies) and on the Internet (federal agencies and Better Business Bureau).

The Humane Society of the United States (HSUS) works towards a humane and sustainable world for all animals, including people, through public education, legislation, and litigation, and is the nation's largest animal protection organization with over eight million members and constituents. While The HSUS will do what it can to help you resolve your complaint, we cannot promise that an outcome will be what you hope for. The HSUS is not a law enforcement agency, nor a legal firm, but rather an organization dedicated to using its resources to help advance the cause of animal welfare across the globe. Due to the large volume of breeder complaints received by The HSUS on a daily basis, we cannot guarantee a response within a certain time period, although every effort will be made. In most cases we will be in touch should we require additional information.