Fill and Sign the Emotional Support Dogs for Witnesses in Court Form

AFFIDAVIT FOR SUMMONS FOR DANGEROUS OR VICIOUS DOG AFFIDAVIT FOR SUMMONS FOR DANGEROUS OR VICIOUS DOG ........................................................................\ .................. OWNER OF DOG (LAST, FIRST, MIDDLE NAME) [ ] MINOR ........................................................................\ ..................ADDRESS ........................................................................\ ..................ADDRESS TELEPHONE NUMBER ........................................................................\ ..................CUSTODIAN OF DOG (LAST, FIRST, MIDDLE NAME) ........................................................................\ ..................ADDRESS ........................................................................\ ..................ADDRESS TELEPHONE NUMBER ........................................................................\ .................. NAME OF PARENT/LEGAL GUARDIAN OF MINOR DOG OWNER ........................................................................\ ..................ADDRESS ........................................................................\ ..................ADDRESS TELEPHONE NUMBER Commonwealth of Virginia VA. CODE §§ 3.1-796.93:1, 3.1-796.93:3 ........................................................................\ ....................................................... ....... General District Court CITY OR COUNTY I, the undersigned applicant, [ ] a law enforcement officer [ ] an animal control officer in the above-named city/county, st ate under oath that 1. I have reason to believe that the canine or crossbreed described below is a dangerous or vicious dog based upon the following: ........................................................................\ ....................................................... ........................................................................\ ................................ [ ] Continued on attached sheet. 2. The canine or crossbreed is described as follows: ........................................................................\ .. ........................................................................\ .. ........................................................................\ ...............................................................................................................................\ ................................ 3. The canine or crossbreed is at the following location:...................................................................... ........................................................................\ . ........................................................................\ ...............................................................................................................................\ ................................ 4. To the best of my knowledge and belief, the person who is responsible for the canine or crossbreed is [ ] the dog’s ow ner, ........................................................................\ .......... [ ] the dog’s custodian, .......................................................................\ .... [ ] a minor, whose custodial pa rent/legal guardian’s name is ................................................................. ..................................................................... [ ] ........................................................................\ ..........................................................................................................................\ ............................... 5. [ ] I have personal knowledge of the fact s set forth in this affidavit. [ ] I was advised of the facts set forth in this a ffidavit, in whole or in part, by another person whose credibility or th e reliability of the information may be determined from the following facts: ........................................................................\ ...............................................................................................................................\ ................................ I request the issuance of a S UMMONS – D ANGEROUS OR VICIOUS DOG to the person(s) identified above pursuant to [ ] Virginia Code § 3. 1-796.93:1 [ ] ........................................................... of ......................... ........................................................................\ .......... LOCAL ORDINANCE [ ] COUNTY [ ] CITY [ ] TOWN .......................................... ________________________________________________ DATE [ ] LAW ENFORCEMENT OFFICER [ ] ANIMAL CONTROL OFFICER ........................................................................\ ...............................................................................................................................\ ................................ TELEPHONE NUMBER \ PRINT NAME \ AGENCY Subscribed and sworn to before me this day. ............................................... ________________________________________________________ …… DATE \ [ ] MAGISTRATE [ ] NOTARY PUBLIC My Commission Expires ………… FORM DC-395 MASTER 11/06