Statement of Complaint

STATEMENT OF COMPLAINT
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Complaint Number:
Number is assigned by Animal Services
Statement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of person making complaint:

First NameMiddle NameLast NameSuffix
Phone number(s)
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Your address:

Street Address

Street Address Line 2

CityState / Province

Zip Code
I, {nameOf}, do hereby give the following statement to Animal Services of Thurston County, Washington, as an aid to investigation. All facts contained herein are true to the best of my knowledge and belief. (Your statement must contain the basic who, what, why, when, and how as they relate to the witnessed incident. You may be called upon to testify in court regarding this incident.)
Incident date(s):
Time of incident(s):
Address of Offending Animal Owner(s):
Description of Animal(s):
Description of event(s):
Description of event(s):
I REQUEST NON-DISCLOSURE. As a complainant, witness, or victim of a complaint filed with an investigative agency, you have the right to request non-disclosure under RCW 42.56.240(2) at the time of the complaint. NOTE: If the box is left unchecked this statement and information contained within, maybe subject to public disclosure and may be released if requested by parties not involved or associated with this incident.
I certify (or declare) under penalty of perjury under the laws of the State of Washington, that the foregoing is true and correct.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place Form Signed/Filled Out

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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STATEMENT OF COMPLAINT

I certify (or declare) under penalty of perjury under the laws of the State of Washington, that the foregoing is true and correct.