Acknowledgement not to Proceed

• Name of Complainant

• Address of Complainant
  Address

• Taken on

  Date

• Taken by

• Customer Service Request Number:

• Date and Time of Offence

  Date
• Location of Offence
  Address

• Details of Offence

I the undersigned do NOT wish to provide Whitehorse City 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

  Sign
• Acknowledgement witnessed at
  Address

• Acknowledgement made and signature witnessed by Council Officer

  Sign