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               COUNTY OPTION DOG TAX 
               State Form 52694 (R / 1-15) 
               Prescribed by the Department of Local Government Finance 
          
INSTRUCTIONS (See also Indiana Code 6-9-39): 
1. Who Must File:   Any person who harbors or keeps a taxable dog in or near a person’s premises regardless of who 
   owns the dog.  A person who harbors or keeps a taxable dog is liable for the tax. 
2. What is a “Taxable” Dog:  Any dog six (6) months of age or older.  The maximum tax is $5.00 per dog; however, the 
   fiscal body of  a county may  adopt a lesser amount.  List each taxable  dog separately unless applying for a kennel 
   License.  A Kennel License is available for persons breeding, boarding, training or selling dogs.  See below for fees. 
3. Where the Taxes Go:  A seventy-five cent fee  may be retained by the designated tax collector.   The remainder is 
   divided with 20% for canine research and education at Purdue University and 80% may be used by the county for the 
   support of animal care facilities; animal control, including dead animal disposal; reimbursement to farmers for livestock 
   kills; and reimbursement to people who have undergone treatment for post exposure rabies. 
 
                    List the dogs six (6) months of age and older, that you own, harbor or keep. 
                                   Major Color 
        Breed                                   Neutered                Sex               Age          Tag Number      Fee
                                   Minor Color 
                                                                                                                        
                                                 Yes                     Male    
                            ________________ 
                                                 No                      Female 
                                                                                                                        
                                                 Yes                     Male    
                            ________________ 
                                                 No                      Female 
                                                 Yes                     Male                                           
                            ________________ 
                                                 No                      Female 
                                                 Yes                     Male                                           
                            ________________ 
                                                 No                      Female 
                                                                                                                        
                                                 Yes                     Male    
                            ________________ 
                                                 No                      Female 
                                                 More than six (6) taxable                               
                             Dogs kept for 
                                                dogs – maximum fee is $50.00 
KENNEL LICENSE              breeding, boarding, 
                                                 Not more than six (6) taxable 
                            training or sale. 
                                                dogs – maximum fee is $30.00 
If additional space is necessary, please attach additional sheets. 
 
Name (Please print)                                                                       Telephone number (daytime) 
                                                                                          (          ) 
Address (number and street)                                                               Telephone number (nighttime) 
                                                                                          (          ) 
Address (city, state, and ZIP code)                                                       Telephone number (cellular) 
                                                                                          (          ) 
 
I hereby certify that the above is true and correct, and includes all dogs subject to tax. 
 
________________________________________________ _______________________ 
Signature        Date (month, day, year) 
 
                                           RECEIPT FOR COUNTY OPTION DOG TAX  
Name                                       Number of dogs                                 Date (month, day, year) 

Tag number(s)                                                                             Tax collected by: 
                                                Kennel License 
Total fee paid                             Not more than six (6)        More than six (6)