Claimant'S Appeal Form From Adverse Finding Of Dog Warden (Page 2 of 2) in pdf

Claimant'S Appeal Form From Adverse Finding Of Dog Warden Page 2

Questions for Witness No. 2

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)

County

Commissioners

Revised 5/12/2014

Claimant'S Appeal Form From Adverse Finding Of Dog Warden Page 2