The following statutes affect this form: s. 170.03, 170.08, and 172.04, Wis. stats. STATE OF WISCONSIN
Town of ________
________ County
I, the undersigned, [select one: chairperson, representative of the law enforcement agency, or appraiser appointed by the chairperson] of the Town of ________, ________ County, Wisconsin, certify that on the application of ________ ________, residing in the town, I viewed [describe animal or goods], [select one: taken up or found] by ________ ________ and appraise the [select one: animal or goods] to be worth the sum of $________. [If applicable] I further certify that the fee for this certificate is $________ and the charge for travel expenses is $________.
Dated this ______ day of ________, 20__.
[Signature]
Note: Fifty cents may be charged for a certificate under s. 170.03, Wis. stats., and $3 may be charged for a certificate under s. 172.04, Wis. stats. Ten cents for each mile necessarily traveled for an appraisal may be charged for appraisals under s. 170.03 or 172.04, Wis. stats.
