CITATION NUMBER(S):____________________________ COMPLAINT No. 05-______________________
PRIVATE CITIZEN NOTICE OF VIOLATION COMPLAINT FORM
Klamath County Code Section 403.510(4)
Complainant (REQUIRED)
Name:
Address:
City:
Zip Code:
Home Telephone:
Work Telephone:
Owner or Keeper of the Dog(s) (if known)
Name:
Address:
City:
Zip Code:
Home Telephone:
Work Telephone:
Dog(s) Description:
To be completed by Dog Control:
Breed/Type:
Color
Sex
Current License?
Yes / No
License #
Dog’s Name:
Breed/Type:
Color
Sex
Current License?
Yes / No
License #
Dog’s Name:
Breed/Type:
Color
Sex
Current License?
Yes / No
License #
Dog’s Name:
Information Regarding the Violation - A Date, Time and Location are REQUIRED.
Date of the Incident:
Approximate Time: a.m./p.m.
Address where the offense occurred:
City:
Zip Code:
What was/were the dog(s) doing? Describe in detail what happened. (This is Required Information)
You must be willing and able to testify in court. (Attached additional sheets if necessary).
CITATION NUMBER(S):____________________________ COMPLAINT No. 05-______________________
Have you had any previous contact or problems with this/these dog(s)? No Yes
If YES, please explain:
STATUS (Office Use Only)
AFFIRMED DISMISSED
STATE OF OREGON
)
) ss.
County of Klamath
)
I, being first duly sworn, state that: I request that a citation be served in this matter. I am
prepared to testify in Court if necessary. I accept full responsibility for the validity of this
complaint and understand that in accordance with Klamath County Code 403.540(4) if I
knowingly falsify information on this form I could be assessed a penalty of up to $500.
Dated this _________ day of _________________________, 20_______.
___________________________________
Complainant
SUBSCRIBED and sworn