THIS FORM IS FOR DOG BITES OR ATTACKS ONLY !!!
PRINT THIS FORM FOR DOG BITES OR ATTACKS ONLY & , FILL IT OUT AND FAX TO US AT 410-885-2910 , WITH COPIES OF MEDICAL STATEMENT FROM THE PHYSICIAN OR VETERINARIAN, IF THE APPROPRIATE INFORMATION IS ON THE FORM AND ATTACHED PAPERS THE OFFICER WILL INVESTIGATE AND TAKE WHATEVER ACTION HE/SHE FELLS IS ADEQUATE. Please print on this form; This form must be filled out & faxed within 72 hours of the incident. And mail us the original with your signature and keep a copy for your records.
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DOG BITE STATEMENT FORM CECIL COUNTY SPCA NAME OF VICTIM(S) ____________________________________________________________________________________________ ADDRESS _____________________________________________________________________________________________________ _____________________________________________________________ PHONE __________________________________________ DATE OCCURRED ______________________________________ TIME OCCURRED __________________________________________ Person injured Name ________________________________ Animal(s) Injured Name ___________________________ EXACT DETAILS OF WHAT OCCURRED, ___________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ DESCRIPTION OF ANIMAL INVOLVED (OFFENDING ANIMAL) ______________________________________________________ ______________________________________________________________________________________________________________ PET OWNERS NAME ___________________________________________________________________________________________ ADDRESS _____________________________________________________________________________________________________ PHONE _______________________________________________________________________________________________________ HOW YOU KNOW THIS PERSON IS THE OWNER __________________________________________________________________ ______________________________________________________________________________________________________________ I SOLEMNLY AFFIRM UNDER THE PENALTIES OF PERJURY AND BASED UPON PERSONAL KNOWLEDGE THAT THIS STATEMENT IS TRUE AND I AM COMPETENT TO TESTIFY ON THESE MATTERS. SIGNED ______________________________________________________ PRINT NAME ____________________________________ DATE ________________________________________
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