• Name of Complainant

  • Address of Complainant
  • Taken on

  • Taken by

  • SR Number

  • Date and Time of Offence

  • Location of Offence
  • Details of Offence

I the undersigned do NOT wish to provide the Mornington Peninsula Shire Council with a sworn statement in regard to the offence(s) listed above. I acknowledge that Council Officers have explained the legislation to me including what my options are under the legislation. I further acknowledge that by me not providing a sworn statement to Council they are unable to pursue the offender in this matter.

The Council Officers have explained to me that Council considers any dog attack, or bite, or chase, or worry, or rush, as a serious matter for both the victim of the incident and the community in general, who are in effect potential future victims. The Council Officers have explained to me that this matter may be dealt with by a Penalty Infringement Notice or by a Magistrates' Court. I have been advised that the Magistrate has the discretion to order the destruction of the dog (if the circumstances warrant that action), and can also order the owner of the dog to pay medical and other expenses incurred as a result of the animal's behaviour that caused some injury.

I understand that my signing of this document signifies that I do NOT want Council to take any further action on my behalf in this matter. However, my signing the document does not preclude me from taking civil action against the owner(s) of the dog.

  • Signed by Complainant

  • Acknowledgement witnessed at
  • Acknowledgement made and signature witnessed by Council Officer

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.