This is Approved Form AF2010-35 made under section 147 of the Domestic Animals Act 2000 

	Post to:	Deliver to:
	The Registrar	The Registrar
Use this form where information is sought for	Domestic Animals Service	Domestic Animals Service
the purpose of seeking compensation under	GPO Box 158	Mugga Lane
section 55 of the Domestic Animals Act 2000	CANBERRA  ACT 2601	SYMONSTON  ACT 2609

Details
First Given Name	Last Name
		
House Number	Street
		
Suburb	Postcode
		
Phone (h)	Phone (w)	Phone (Mobile)
			
I	
My child/dependant	 Name:  ________________________________________________________
My Client	 Name:  ________________________________________________________
My animal	 Name:  __________________________Rego No:  _____________________
was involved in an incident with a dog.
Date of attack/harassment:        ___________________________________________________________________________________
Location:          ___________________________________________________________________________________
Time:          ___________________________________________________________________________________
Details of injury/or damage    
	____________________________________________________________________

	____________________________________________________________________

	____________________________________________________________________

I would like to access the owner’s details in relation to an attack/harassment by a dog DAS Reference Number: (if known) ___________________________________________________________________
I have attached evidence of my/my client’s out of pocket expenses:  
Signed:_________________________________  Date: ______________________
Print Name:  ____________________________
Who can sign this form:  The victim or their legal representative, the victim’s parent or guardian.