Form 955-A - Animal Claim Page 2
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1
2REPORT OF DOG WARDEN’S INVESTIGATION OF
ANIMAL(S), FOWL, OR POULTRY KILLED OR INJURED BY DOGS
(Claimant does not complete this page)
Loss or injury discovered by claimant:
Date ___________________
Time _______________ A.M.
P.M.
Loss or injury reported to Dog Warden:
Date ___________________
Time _______________ A.M.
P.M.
Loss or injury investigated by Dog Warden:
Date _____________________
Owner of livestock ___________________________________________________________________________
Address _________________________________________________________ Phone _____________________
Township ________________________________________________________
Caretaker of livestock (if claimant is other than owner) _______________________________________________
Address ____________________________________________________________________________________
Witness of loss or damage:
1. Name ________________________ Address ___________________________________ Phone _____________
2. Name ________________________ Address ___________________________________ Phone _____________
3. Name ________________________ Address ___________________________________ Phone _____________
4. Name ________________________ Address ___________________________________ Phone _____________
Location of loss or injury: Address _________________________________ Township ______________________
NUMBER
KIND OF ANIMAL
STATE WHETHER
FAIR
KILLED OR
FOWL, OR
BREED/TYPE
SEX
AGE
WEIGHT
KILLED OR STATE
MARKET
INJURED
POULTRY
INJURY INFLICTED
VALUE
Amount of total damages $_______________________
Deduction for carcasses or pelts sold or used $_______________________
Net Damages $_______________________
Description of dog(s) causing damage _______________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Owner(s) of dog(s) involved (also give owner’s address) ________________________________________________
______________________________________________________________________________________________
Does claimant own dog(s)? Yes _______ No _______
Is it registered? Yes _______ No ______
Registration number(s) _________________________________________________________________________
Are any unregistered dogs kept or harbored on claimant’s property? Yes _______ No _______
Remarks ______________________________________________________________________________________
______________________________________________________________________________________________
Claim shall be allowed in its entirety:
Yes ______________
No ______________
Claim shall be disallowed in its entirety
Yes ______________
No ______________
If claim is to be allowed in part, state the correct loss or injury and the fair market value thereof: ________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
I have investigated the above claim and certify that this report is a correct statement of that investigation.
_________________________________
(Signature of Dog Warden)
__________________________________
(Date)
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