Rev. 5/25

Last Name	First Name(s) and Age(s)  	
Mailing Address  	
Street or P.O. Box, Town, State, Zip

County	Phone	Year

 	
Club	Member’s Birthday (Month, Day, Year)

NEBRASKA 4-H DAIRY GOAT IDENTIFICATION AFFIDAVIT
See reverse side for important instructions and lease affidavit.

REGISTERED  	

GRADE  	

BREED 	

BRED BY EXHIBITOR:	YES  	

NO  	

Name of Animal  	
Tattoo or Scrapie Ear Tag No. Right	Left  	

Registry No.  	
Date Born  	
Month	Day	Year

[Need at least one of these forms of ID (tattoo, tag or vaccination tag) for animals without distinct markings.]
Sketch markings and include colors or attach photographs showing both sides of face.

I (we) certify that this is a 4-H project animal this year and that to the best of my (our) knowledge the above information is correct.
Date   	

Signature of 4-H Member(s) (At least one of those listed above must sign.)

This (these) youth has (have) submitted this livestock identification affidavit in accordance with all rules of the state and county 4-H Program and also has (have) successfully completed a Youth for the Quality Care of Animals program for this period.
Date   	

Parent Signature

Extension Staff Signature