Claimant'S Appeal Form From Adverse Finding Of Dog Warden printable pdf download

Form 955-B Prescribed by:

JON HUSTED

Ohio Secretary of State

Central Ohio: (614) 728-9200

Toll Free: (877) SOS-FILE (767-3453)

ClientServiceCenter@OhioSecretaryofState.gov

CLAIMANT’S APPEAL FROM ADVERSE FINDING OF DOG WARDEN

(To be filed with the Board of County Commissioners or a member thereof not later

than ten (10) days after adverse finding by Dog Warden. R.C. 955.29)

Presented to the Board of Commissioners of ____________________________ County, Ohio,

on the ________ day of ______________________, 20____.

Net damages claimed by owner

$_________________

Net damages allowed by Dog Warden

$_________________

Other adverse findings by Dog Warden _______________________________________________________

_______________________________________________________________________________________

-------------------------- (CLAIMANT DOES NOT COMPLETE BALANCE OF FORM) -------------------------

Questions for Witness No. 1

1. What is your name and address?

______________________Address _________________________________ Township______________

2. Are you related to the claimant in any way? Yes _____ No _____ If “yes”, state relationship

__________________________________________.

3. Have you any interest, direct or indirect, in the ownership of the animals, fowl, or poultry killed or

injured? Yes _______ No _______

4. Have you any interest, direct or indirect, in the claim for damages? Yes _______ No _______

If “yes”, state interest___________________________________________________________

5. Did you view the animal(s), fowl, or poultry killed or injured? Yes _______ No _______

If “yes”, state when and where____________________________________________________

6. Was the damage done in whole or in part by any dog or other animal kept or harbored by the claimant,

or by any employee or tenant upon the claimant’s premises? __________________________________

___________________________________________________.

7. Do you know the identity of the owner of the dog or dogs committing the injury? Yes _____ No _____

If “yes”, identify owner _______________________________________________________________

8. Is the claimant’s statement correct as to the number of animals, fowl, or poultry killed or injured?

Yes _______ No _______

9. If the claimant’s statement is incorrect, state the number of animals killed and/or injured.

___________________________________________________________________________________

10. Is the claimant’s statement correct, just, and reasonable as to the fair market value of the animal(s), fowl,

or poultry killed and/or injured? Yes _______ No _______ If “no”, state your opinion as to the fair

market value _______________________________________.

11. Could any value be attached to the carcass(es), or the pelt(s) of the animal(s), fowl or poultry killed?

Yes _______ No _______ If “yes”, how much? ____________________________________.

THIS STATEMENT IS MADE SUBJECT TO THE CRIMINAL PENALTIES FOR FALSIFICATION

PROVIDED FOR IN SECTION 2921.13 OF THE REVISED CODE.

______________________________ ____________________________________ _________________

(Signature of Witness)

(Address of Witness)

(Date)

Revised 5/12/2014

Claimant'S Appeal Form From Adverse Finding Of Dog Warden

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