Form 955-A - Animal Claim printable pdf download

Form No. 955-A. Prescribed by the Secretary of State (05-07)

__________________________________________________________________________________________________________________________

ANIMAL CLAIM

(To be completed in duplicate by Claimant for loss or injury caused by a dog(s) to animals, rabbits, fowl, or

poultry having an aggregate value of ten dollars ($10) or more. The amount of the claim shall not exceed

the lesser of five hundred dollars per animal or the uninsured amount of the loss or injury.)

Revised Code Sections 955.29 through 955.37

____________________________________

To the County Commissioners of __________________________________ County, Ohio:

The following claim for loss or injury to horses, sheep, cattle, swine, mules, goats, domestic rabbits, or aborted

fetuses of such animals, or domestic fowl or poultry, which have an aggregate fair market value of ten dollars or

more, and which is caused by a dog(s) which is not owned or harbored by the owner of such animal(s), is submitted.

NUMBER

KIND OF

AMOUNT

STATE WHETHER

KILLED

ANIMAL,

BREED/

MARKET

OF MONEY

KILLED OR STATE

AGE

SEX

WEIGHT

FOWL, OR

TYPE

VALUE

CLAIMED

INJURY INFLICTED

INJURED

POULTRY

FOR LOSS

Total claim for damages $ __________________________

Deduction for carcasses or pelts sold or used $ _________________________

Net damages claimed $ __________________________

Date loss or injury discovered ___________________________________

Date reported, if loss or injury, was reported by claimant to Dog Warden ___________________________________

Owner of animal(s), fowl, or poultry, which has been killed or injured ______________________________________

______________________________________________________________________________________________

Address of the owner _________________________________________________ Phone _____________________

Township __________________________________________________________

Address where loss or injury occurred ____________________________________ Phone _____________________

Township where loss or injury occurred ___________________________________

On the date of the above loss or injury, did claimant own or harbor an unlicensed dog required to be licensed under

Section 955.01, Revised Code? Yes_____________ No ______________

The owner(s) of the dog or dogs committing the injury is known: Yes _______ No _______

If “yes”, state name

and address of the owner(s) ______________________________________________________________________

_____________________________________________________________________________________________

The claimant has an insurance policy or policies which cover all or any portion of the loss or injury:

Yes _______ No _______

If yes, indicate the name of insurance company or companies ____________________

_____________________________________________ Policy numbers __________________________________

______________________________________________________________________________________________

THE CLAIMANT STATES THAT HIS CLAIM FOR DAMAGES IS JUST AND REASONABLE, THAT

THE ABOVE INFORMATION IS TRUE, AND THAT HIS STATEMENT IS MADE SUBJECT TO THE

CRIMINAL PENALTIES FOR FALSIFICATION PROVIDED FOR IN SECTION 2921.13 OF THE

REVISED CODE.

___________________________________________

(Signature of person making claim)

___________________________________________

(Address of person making claim)

___________________________________________

(If the claim is made by a person other than the owner,

state the relationship to the owner, i.e., whether tenant

or an employee)

INSTRUCTIONS

1. Claimant must notify a Commissioner or the Dog Warden within 72 hours of discovery of the loss or injury.

2. Claimant must complete and execute form in duplicate.

3. Claimant must submit a copy of his insurance policy or policies if so insured.

4. A fetus that is aborted by an animal because of stress inflicted by a dog(s) and which does not on that account

survive, shall be considered to be killed and claim may be made for its loss. (The Dog Warden, as part of his

investigation, may request the Chief of the Division of Animal Industry to have a state veterinarian certify the

cause of death.)

5. If claimant was the owner or harborer of an unregistered dog, no recovery from the Dog Kennel Fund is allowable.

Form 955-A - Animal Claim

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